Project Name

/ Site No
Monthly Site HSE Performance Report Client
Consultant
Total HSE
HSE Performance Report for the Month of - Staff at Site

Manpower & Manhours Details -

Avg
Cumulative
Mandatory Manpower Man hours
Trade/Desgn Nos Trade/Desgn Nos Nos Man hours till
Certified Personnel for the Current Month
Last Month
Month

Engineers Labourers Rigger

Remarks :
Sr Foreman
Electirician Scaffolder
/foreman

Asst Foreman Pipe Fitter First Aider

Confined Space
Ganger Operators
Workers

Carpenter Drivers Fire Wardens

Mason Sub Contractors Male Nurse

Steel Fixers Others

Induction Training (All Employees absent above 14 days from site to be reinducted)

H-F-07
Revision 01
24-01-2016
 No of Persons Newly Joined No. of person joined after 14 days No. Induction sessions conducted
Initial Induction Re-Induction
continous absence during the month

Tool Box Training Total Number of tool box conducted across the Project during the mon

Average time of Total Persons

Areas Activity Name of the Person conducted No. of sessions
each session covered

HSE Training (Internal & External)

Date Sessions / Hours Venue FACULTY TARGET PARTICIPANTS

Total Hours Taken For Induction Total Hours Taken For TBT Total Hours Taken For Internal Trainings

Total Training Hours For Induction, TBT & Trainings for the Month 0

Accident (LTI) / Near Miss Incident (NM) / First Aid (FA)/ Vehicular accident (VA)/ Property Damage(PD)Service DamageDetails(SD

H-F-07
Revision 01
24-01-2016
 Description
S/No Date Incident Type Part of the body Injured / damage incase of Causative Factor
vehicle

Risk Assessment:

Risk Assessments Carried out this

Total Number of Risk Assessments Carried Out For The Project Total Number of Risk Assessments Reviewed (Date)
Month

Sub Contractor Details :

Total No. of Sub-Contractors No. of Inspections Performed On Sub-Contractors No. of Review/Approval of Sub-Contractor EH

No. of Site Audits Performed on Sub-Contractor

No. of Full EHSMS Audit Performed on Sub

Sub-Contractor Incidents investigated by Entity

Corrective Notices Issued to Sub-Contr

Breach Notices issued to Sub-Contractors

H-F-07
Revision 01
24-01-2016
Client / Consultant Inspection or Audit :

Date Inspected By Number of Observations Specify the Open / Pending Ob

Other Information: Date Remarks

Safety committee meeting :

Site Safety Walk:

HSE Awards/Appreciation

NOC'S - No Objection Certificate

Description ( Authority / Agency ) Date Of Issue Date Of Expiry

Date of compilation: Singature of HSEA Singature of P.M

Main copy will be submitted to P.M before 4th of each month with a copy to HSEM, Sr. HSEA , HSE CO-OD , HSE SECRETARY & Site safety committee members

H-F-07
Revision 01
24-01-2016
 Cumulative Man Hrs from the start of Year 2015

m site to be reinducted)

H-F-07
Revision 01
24-01-2016
 Number of People Inducted from the start of Project

Initial Reinduction

cross the Project during the month

Main Topics covered

No. of person
Training Topic covered
Attended

Total Hours Taken For External Trainings

D)Service DamageDetails(SD)

H-F-07
Revision 01
24-01-2016
 Learning
Corrective & Preventive Action Taken
Points

Remarks

iew/Approval of Sub-Contractor EHS Procedures

ull EHSMS Audit Performed on Sub-contractor

rrective Notices Issued to Sub-Contractors

H-F-07
Revision 01
24-01-2016
 Specify the Open / Pending Observations

Remarks

Date Of Expiry

Singature of P.M
e safety committee members

H-F-07
Revision 01
24-01-2016
 PROJECT ENVIRONMENTAL REPORT -
Site Number & Name.: Client Name:

Report prepared
Consultant Name: by:
1. Environmental Training
Description of Environmental Tool Box Talk / Regular Trainings

Sl No Date Subject Time No. Of Attendees

2. Monitoring

Date of
Nature of Monitoring (Air/Water/Noise, etc) Monitoring

Monitoring Done by Remarks

3. Audits/Inspections
No. of Environmental Non-Conformances Ra
Nature of Inspection No of Open
No. of Inspections Major NCR's Minor NCR's NCR's

4. Solid Waste Management

No of Skips
Waste Contractor assigned for the project
present

Disposal
Volume of Each Skip
Frequency

Loading Type of Unloading

Quantity RSP
Date Waste Date

Food
Concrete
Metal
Wood
Nails
Waste Oil
Used
Batteries
Paper
Toners
Plastic
 Bitustick
Hazardous
Waste
Asphalt
Other -
specify
5. Effluent Waste Management

Waste Contractor assigned for the project or Self

Disposal Frequency
Type of Waste Quantity Removed this Month Disposed as per CWM Norms (Loca
Liquid Effluent
Liquid - Other
Other - specify
6. Consumption
Quantity of fuel used on site: Litres
Quantity of potable water used on site: Litres
Electricity : kWH

7.Environmental Rewards/Fines

Env. Awards/ Appreciation

Fines

8. Other

Status of
Status of CEMP with Status of Env. Aspects & Env. Concrete
No of Drip Trays
Rev No Impacts Objectives & Washout Area
Targets

I hereby confirm that all details furnished above are true and can be verified

Name Signature
 RT -

rainings

Attendees Remarks

al Non-Conformances Raised

Remarks

Recycling
Company Landfill-
Facility-
Truck No. Location
Location
ed as per CWM Norms (Location)

No of Spill
No of Drip Trays
kits/Arrangements

can be verified
 Date
Month
Year

MONTHLY HSE STATISTICS REPORT - HILALCO

S.NO SUBJECT NO'S
1 No. of unsafe acts & condtions

2 No. of closed unsafe acts & conditions

3 No. of outstanding Unsafe Acts & Conditions

4 No. of LTI'S (Lost Time Incidents)
5 No. of Fatalities

6 No. of Occupational Illness

7 No. of Medical Treatment Cases

8 No. of on-site First Aid Cases

9 No. of Equipment & Property Damage

10 No. of Near Misses

11 No. of Inductions

12 No. of Re-Inductions

13 No. of TBT'S (Tool Box Talk)

14 No. of Internal Trainings

15 No. of External Trainings

16 No. of Empowerment to Stop Work

17 No. of HSE Walks

18 No. of HSE Committee Meetings

19 No. of HSE Awards

20 No. of Good Practices

21 No. of Fines & Penalties
22 No. of NCR'S
23 No. of HSE Inspections (Consultant & Client)
24 No. of HSE Audits
 Date
Month
Year

MONTHLY HSE STATISTICS REPORT -

SUB CONTRACTORS
S.No SUBJECT NO'S

1 No. of unsafe acts & condtions

2 No. of closed unsafe acts & conditions
3 No. of outstanding Unsafe Acts & Conditions
4 No. of LTI'S (Lost Time Incidents)
5 No. of Fatalities
6 No. of Occupational Illness
7 No. of Medical Treatment Cases
8 No. of on-site First Aid Cases
9 No. of Equipment & Property Damage
10 No. of Near Misses
11 No. of Inductions
12 No. of Re-Inductions
13 No. of TBT'S (Tool Box Talk)
14 No. of Internal Trainings
15 No. of External Trainings
16 No. of Empowerment to Stop Work
17 No. of HSE Walks
18 No. of HSE Committee Meetings
19 No. of HSE Awards
20 No. of Good Practices
21 No. of Fines & Penalties
22 No. of NCR'S
23 No. of HSE Inspections (Consultant & Client)
24 No. of HSE Audits
 Monthly Site Inspection Checklists / Permits
S.No Check List Yes No No. of Inspections Date of Inspection Conducted

1 Machinaries & Eqiupment Inspection

2 Portable Power Tools

3 Lifting Tools & Tackles
4 Electrical DB/ELCB Inspection
5 Housekeeping
6 Environmental Inspection
7 Excavation Checklist
8 Fire Extinguisher Inspection
9 Gas Cutting Works Inspection
10 Hand Tools Inspection
11 Scaffolding Inspection
12 Welding Inspection Checklist
13 Hot Work Permits
14 Confined Space Entry Permit
15 Excavation Permit
16 Spill Prevention Control
17 Training Need Analysis

18 Risk Register Updated

SITE HSEA:- HSEA SIGNATURE DATE:-

 PROJECT -
Fire Extinguishers Internal Monthly Inspection Report -
Inspection Carried Out By: Date & Time:
Fire Extinguisher Date of Condition of Extinguisher

SL No. Location Weight of

Last External Inspection Discharge
Type Capacity ID No. Purchase Last Refill CO2 Ext.in
Inspection tag/sticker Hose/nozzle
Kg

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
 24
25
26

TOTAL NO OF CO2 =
TOTAL NO OF DCP =
TOTAL NO OF FOAM =
GRAND TOTAL =

Special Remarks : HSEA SIGNATURE :

Report -
Date & Time:
ition of Extinguisher
Pressure of Remarks
DCP/Foam type Visual Seal
Ext. in Bar
=
=
=
=
 Project -

Site HSE Assest Report For the Month of -

Working & Well Calibration Due Date
S.NO HSE ASSEST Location Remarks
Maintained (Yes/No) ( If Applicable)

Note : HSE assets = Camera (HSEA), Cable detector

(SK), Gas detector (SK), B.A. Set (SK), Air Line
Respirator (SK).
To be send to HSE secretary every month along with
Monthly HSE report.
HSEA SIGNATURE :
 10
12

0
2
4
6
8
No. of unsafe acts & condtions

f closed unsafe acts & conditions

tanding Unsafe Acts & Conditions

No. of LTI'S (Lost Time Incidents)

No. of Fatalities

No. of Occupational Illness

No. of Medical Treatment Cases

No. of on-site First Aid Cases

f Equipment & Property Damage

No. of Near Misses

No. of Inductions

No. of Re-Inductions

No. of TBT'S (Tool Box Talk)

No. of Internal Trainings

No. of External Trainings

o. of Empowerment to Stop Work

No. of HSE Walks

No. of HSE Committee Meetings

MONTHLY HSE PERFORMANCE REPORT - HILALCO

No. of HSE Awards

No. of Good Practices

No. of Fines & Penalties

No. of NCR'S
 No. of unsafe acts

No. of closed unsafe acts

No. of outstanding Unsafe Acts

No. of LTI'S (Lost Tim

No.

No. of Occupati

No. of Medical Treat

No. of on-site Fir

No. of Equipment & Proper

No. of

No. o

No. of R

No. of TBT'S (To

No. of Intern

No. of Extern

No. of Empowerment t

No. o

No. of HSE Committ

No. of

No. of Go

No. of Fines
 O
No. of HSE Awards

No. of Good Practices

No. of Fines & Penalties

No. of NCR'S

Inspections (Consultant & Client)

No. of HSE Audits

 No. of

No. of Go

No. of Fines

No. of HSE Inspections (Consulta

No. of
 0
2
4
6
8
10
12
No. of unsafe acts & condtions

No. of closed unsafe acts & conditions

o. of outstanding Unsafe Acts & Conditions

No. of LTI'S (Lost Time Incidents)

No. of Fatalities

No. of Occupational Illness

No. of Medical Treatment Cases

No. of on-site First Aid Cases

No. of Equipment & Property Damage

No. of Near Misses

No. of Inductions

No. of Re-Inductions

No. of TBT'S (Tool Box Talk)

No. of Internal Trainings

No. of External Trainings

No. of Empowerment to Stop Work

No. of HSE Walks

No. of HSE Committee Meetings

No. of HSE Awards

MONTHLY HSE PERFORMANCE REPORT - SUB CONTRACTORS

No. of Good Practices

No. of Fines & Penalties

No. of NCR'S

o. of HSE Inspections (Consultant & Client)

No. of HSE Audits

 No. of u

No. of closed u

No. of outstanding Un

No. of LTI'

No.

No. of M

No. of

No. of Equipme

No.

No. of Empo

No. of HS

No. of HSE Inspection

 No. of NCR'S

o. of HSE Inspections (Consultant & Client)

No. of HSE Audits

No. of HSE Inspection