Safety Arabtec Forms

INCIDENT / NEAR MISS INVESTIGATION REPORT
Location: Report No.

Date of Incident/ Near Miss: Time:
Category : Incident Near Miss Property Damage Environmental Incident

(Major Incident is any significant event, that has the potential to cause either:
serious injury, cases of ill health, loss of life, serious disruption or substantial
Incident Rating: Minor Major amount of damage to property or environment.)
Property Damage/ Environmental

Near Miss Injuries
Incident
Description Details (Name, No., ….) of person(s) involved and (Brief description of the damage to property or
brief description of the injuries environmental incident.)
Arabtec
Others
(Client,
S/c, Third
Party)
Details of persons hospitalised
Sr. No. Name Company Designation Name of Hospital
Details of Machinery / Vehicles involved in the incident/near miss:
Machinery/Vehicle
Sr. No.
Description Registration No. Driver / Operator Name & Company
1
2
3
Page : 1 of 6 Form # 10001-Rev.3-April-12




Near Miss Investigation into The Root Causes
Injuries
Incident
I- Immediate causes (Why did the incident happen?) (Check all that apply.)
I-A UNSAFE CONDITION
01 Inadequate/ Improper Access 03 Failure/ Inadequate tool or equipment
02 Poor Working Environment 04 Inadequate/ Defective Warning sign/Safety devices
□ Fumes 05 Poor housekeeping
□ Heat 06 Lack/ Inadequate/ Inappropriate PPE
□ Excessive noise 07 Lack/ Insufficient training
□ Dust 08 Others (Specify):
□ Inadequate illumination
□ Inadequate ventilation
I-B UNSAFE ACT

01 Failure to follow rules and procedures 08 Operating at unsafe speed (exceeding speed limits)
02 Incorrect/ Misuse of equipment/ tools 09 Servicing equipment while power is on (No LOTO).
03 Failure to use warning or Safety devices 10 Removing safety guard.
04 Improper handling 11 Using defective equipment
05 Failure to wear PPE 12 Unsafe lifting (Mechanical / Manual)
06 Taking short cuts. 13 Distraction, teasing, horseplay
07 Operating without permission 14 Others (Specify):
II- Underlying causes

01 Inadequate knowledge and/or skill 05 Inadequate maintenance and/or inspection
02 Lack of supervision 06 Inadequte work standard and/or procedure
03 Inadequate planning and /or organization 07 Inadequate instructions or training
04 Inadequate Engineering design 08 Others (Specify):
III- Type of Injury: (in case of no injury please check here □)

01 Amputation 11 Foreign body in eye
02 Abrasion/ Bruising/ Scratch 12 Fracture/Broken bone
03 Bite/Sting 13 Hernia
04 Burns/ Scalds 14 Illness (Specify):
05 Concussion (to the head) 15 Internal injury
06 Crushing Injury 16 Poisoning (e.g. food poison)
07 Cut / Laceration / Puncture 17 Reaction to chemical exposure
08 Damage to a body system: (e.g.: nervous, 18 Repetative stress injury
respiratory, or circulatory systems) 19 Splinter
09 Dislocation 20 Strain/Sprain
10 Exposure to heat/ Cold 21 Others (Specify):




IV. Part of body
Near affected:
Miss (shade all that apply)
Injuries
Incident
V- Type of Injury by Cause :

01 Act of Violance / Horse play 11 Falls from height
02 Materials Handling (Manual / mechanical) 12 Handling / Use - hand tools
03 Contact with / trapped by moving machinery/parts. 13 Handling / Use - power tools
04 Contact with hot surfaces/welding flashes 14 Road Accident / struck by moving plant
05 Contact with electricity/ Electrical work 15 Fire / Explosion
06 Failure of working equipment 16 Struck against /fixed object/ Ground
07 Exposure to Toxic subtances/ Gases 17 Stripping on /slips/trips/ falls on the same level
08 Trapped by something collapsing or overturning 18 Others (Specify):
09 Struck by moving/ Falling/ Flying objects / materials
10 Collapse of structure / excavation
VI- Describe in details the Incident/ Near Miss




VII- Incident/Near
Near Miss Root CausesInjuries
Miss
Incident
VIII- What are the control measures that could have prevented this Incident/
Near Miss ?
IX- What changes do you suggest to prevent this Incident/Near Miss from
happening again? (Check all that apply.)
q Stop this activity q Guard the hazard q Train the employee(s) q Train the supervisor(s)
q Redesign task steps q Redesign work station q Write a new policy/rule q Enforce existing policy
q Routinely inspect for the hazard q Personal Protective Equipment q Other:
Explain the changes required as indicated above:
X- Actions taken to close out the report:
Report Closed - Name:




Near Miss Injuries
Attachments (please tick) Incident
Medical Report Form # 10014 Written witnesses statements
Police Report Photographs
Maps / drawings
Others (pl. specify) __________________________________________________________________
Comments (If any)
Report Prepared by:

Name: Signature:
Position: Date:
Names of investigation team members:
Name(s): Signature:
Position: Date:
Reviewed by (Manager In Charge):
Name: Signature:
Position: Date:
CC: Admin Manager (for incidents only) CC: HSEQ Senior. Manager & MR (H.O.)
Insurance (for incidents only)

SUMMARY SAFETY REPORT
PROJECT:
REPORTING PERIOD: From: To Date:
(1) MAN HOURS* WORKED

Arabtec Man hours from Arabtec Man hours Arabtec Man Hours
Start (Cumulative) (A) The Period (B) (Cumulative) (A+B)
Subcon. Man hours from Subcon. Man hours Subcon. Man Hours
Start (Cumulative) (A) The Period (B) (Cumulative) (A+B)
GRAND TOTAL
(2) ACCIDENTS
Total To Date
S/N Type of accident From Start For the period
(cumulative)
1 Near Misses
2 First Aid Case (FAC)
3 Medical Treatment Case (MTC)
4 Restricted Work Case (RWC)
5 Lost Workday Case (LWC)
6 Permanent Partial Disability (PPD)
7 Permanent Total Disability (PTD)
8 Fatality (F)
9 Lost Time Injury (LTI) = LWC+PPD+PTD+F
(3) MAN DAYS LOST
From start (Cumulative) For the Period To date (Cumulative)
(4 A ) SEVERITY RATE
Formula Calculation Result
Total Man Days Lost X 1000000

Total No. of Manhours Worked
(4 B ) INCIDENT FREQUENCY RATE
Formula Calculation Result
No of Lost Time Incident X 1000000

Total No. of Manhours Worked
1 of 3 Form # 10002-Rev 5- Dec 11

PROJECT:
(5) OTHER ACTIVITIES

For To date
S/N Types From Start
the period (cumulative)
1 Safety Corrective Action Reports ( SCAR)
2 Safety Awards
3 Safety Violation
4 Training :
a) Safety Induction
b) Tool Box Talk
c) Others
(6) Type of Injury by Cause :

No. of
occurance No. of occurance
Injury Type Injury Type
during the during the month
month
Falls to below
01 Act of Violance / Horse play 11 ground level
02 Collapse of structure / Handling materials

12
excavation / manual lifting
Handling
Contact / trapped by
03 13 /materials-
machinery
mechanical
Contact with hot metal/ Handling / Use -
04 welding flaches 14 hand tools
Contact with electricity/ Handling / Use -
05 15
Electrical work power tools
Road Accident /
06 Fire / Explosion 16 struck by moving
plant
Stripping on
07 Exposure to Toxic subtances/
17 /slips/trips/ falls
Gases
on level
Struck against
08 Failure of working equipment fixed object/
18
ground
09 Falling objects / materials 19 Others
10 Falls from height
2 of 3 Form # 10002-Rev 5- Dec 11

PROJECT:
(7) Record of Last LTI

Total Man Hours
Name MB # to date
for the period
(cumulative)
(8) Remarks:
HSE Staff Name: ________________ PM's Name: ________________
Signature ____________________ Signature _________________
3 of 3 Form # 10002-Rev 5- Dec 11

FIRE EXTINGUISHER MONTHLY INSPECTION
LOCATION MONTH DATE
FIRE EXT. NO. CAPACITY/ LOCATION VALIDITY SHIELDED VISUAL LOCK INSP. PRESSURE DISCHARGE DISCHARGE REMARKS/
TYPE (12 FROM SUN SEAL PIN TAG GUAGE HOSE NOZZLE ACTION
(eg. 7 Kg CO2) months)
Visual Seal : Check for cracking/denting in the case Pressure Guage : Check for cracking/denting in the case
Lock Pin Check : Check that the lead seal on the wire clip which holds : Check that the guage is green, not red
the pin on the handle in place is not broken. Discharge Hose : Check for cracking/splitting at the discharge nozzle
Inspection Tag : Check that the sticker indicating last checking
details of the extinguisher is in place. Discharge Nozzle : Check to see if it is cracked/broken
Inspected By: Page : of Form # 10003-Rev 1-Jun 09

Project Name & No
HSE MANAGEMENT - CHECKLIST
LOCATION / AREA:
Sl. Activities / Items to be Inspected Remarks by Safety staff

No.
1 Availability and awareness of the

approved site HSE manual.
2 Posting and awareness of ARABTEC

(Health Safety & Environment) HSE
Policy.
3 Operation of an effective training

programme in accordance with the
Training procedure (QSP # I01).
4 Displaying emergency telephone

numbers.
5 Emergency evacuation procedures in

place and staff awareness of the same.
6 HSE Record keeping and related

documentation.
7 Project Safety Notice Board on view.
General / specific observations
ARABTEC – SAFETY ENGR. APPROVAL

SIGNATURE
NAME
DESIGNATION
DATE
Checklist # 10006-Rev 4-Jun 09

Project Name & No
HEALTH ,SAFETY & ENVIRONMENTAL WELFARE FACILITIES & PROVISIONS -

CHECKLIST
LOCATION / AREA:

No.
1 Eating areas
2 Toilet facilities
3 Drinking water availability
4 Wash Area
5 First Aid provisions and availability of

trained personnel.
6 Hazardous & Non Hazardous waste

disposal provisions.
7 Environmental controls in place.

SIGNATURE
NAME
DESIGNATION
DATE

Project Name & No
AVAILABILITY, USE & CONDITION OF PPE - CHECKLIST
LOCATION / AREA :

No.
1 Hard hats
2 Safety footwear
3 Safe clothing
4 Fall protection
5 Eye protection
6 Hearing protection
7 Gloves
8 Respiratory protection
9 Sufficient air movement
10 Sufficient lighting

SIGNATURE
NAME
DESIGNATION
DATE

Project Name & No
TEMPORARY SITE ELECTRICS & POWER TOOLS - CHECKLIST
LOCATION / AREA :

No.
1 Temporary site electrics and use of

ELCBs
2 Guards fitted to power tools
3 Condition of power tools
4 Cutting discs fitted correctly
5 Wiring and connections are suitable for

the voltage being used.
6 Correct PPE for cutting discs.
7 Proper colour coding of temporary

electric boxes.
8 No joints in cabling.
9 Environmental aspect & impact such as

noise and control measure implemented.

SIGNATURE
NAME
DESIGNATION
DATE

HSE WARNING LETTER / DISCIPLINARY NOTICE
1st Warning Ref. No. ______________

2nd Warning
3rd Warning
Dismissal Date: ________________
Employee’s Name : ______________________________________ M.B.No. : __________
Occupation : _____________________________________________________________________
Location / Project Site: _____________________________________________________________________
You have committed the following HSE violation/s:

………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………….….
Therefore, the following disciplinary action will be taken against you:
Wage deduction: 2 hrs. 4 hrs. 1 day 2 days

Suspended from : Date: ____________ to Date: _______________
Dismissal from Site/location : Date: ____________
The employee is hereby warned that he could be dismissed if the violation is repeated after
the 3rd warning.
ORIGINATOR APPROVED BY (MANAGER IN CHARGE / ARABTEC
HSEQ SENIOR MANAGER)
Name: _______________________________ Name: _____________________________
Designation: _______________________________ Designation: _____________________________
Signature: Signature:
_______________________________ _____________________________
Employee Acknowledgement:
I the undersigned have received this Safety warning letter / disciplinary notice and I admit that I
have understood the contents.
Received on: ………………………….. (Date) Signature: ………………………………..…..
CC: Manager In Charge Form # 10010-Rev 3-Jun 09

Site Safety Officer/Engr.
Admin
HSE CORRECTIVE ACTION REPORT (HSE - CAR)
HSE - CAR NO :………………….. DATE :………….. SITE : ………………
Person to
Root cause
SL. No. Corrective Action Action Action Date Closed Y/N
Unsafe act Unsafe
condition
Safety Engineer Project Manager

(Signature)
Form # 10013-Rev 2-Jun 09

ARABTEC CONSTRUCTION (LLC)
P.O.BOX. 3399, Dubai-U.A.E
Tel: 04-3400700, Fax: 3404004
Day_____________
Date____________
Time____________
To:______________________________________________________________________________________________
_________________________________________________________________________________________________
Dear Sir,
We would kindly request you to give necessary treatment to our following employee who had met with an
accident and provide us with your diagnosis.
Name of injured__________________________________________________________Age ( ) years.
Occupation__________________________________________________________M.B. No._______________________
Date of Accident_____________________________________________Time of Accident_______________________

Place of Accident (Site)_____________________________________________________________________________
Nature of Accident__________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Signature____________________________________________________________________________________________________
MEDICAL REPORT
Nature and extent of Accident / Injury_________________________________________________________________

________________________________________________________________________________________________
________________________________________________________________________________________________
____________________________________________________________________________________________________________
Fit for duty_______________________________________________________________________________________

Unfit for duty_____________________________________________________________________________________
Remarks_________________________________________________________________________________________
________________________________________________________________________________________________
Signature of Medical Officer Date____________

FIRST AID RECORD / REGISTER
PROJECT :
DATE NAME MB # COMPANY TYPE OF INJURY TREATMENT GIVEN REMARKS

FIRST AID ITEMS STOCK REGISTER
PROJECT :
STOCK
RECEIVED TOTAL QUANTITY
Sr no NAME BALANCE QUANTITY USED BALANCE IN HAND REMARKS
QUANTITY IN HAND
QUANTITY

HSE CORRECTIVE ACTION REPORT
(HSE-CAR REGISTER)
Site / Location:
IMMEDIATE CAUSES
HSE- PERSON(S) TO UNDERLAYIN CLOSED
SAFETY VIOLATION DATE UN SAFE
CAR No. ACTION G CAUSES
Condition Act Yes No
1 of 1 Form # 10017-Rev 0-Jun 09

ACKNOWLEDGMENT OF COMMITTMENT TO FOLLOW
SAFETY GUIDELINES
SUB-CONTRACTORS TEN GOLDEN RULES
I, ____________________ the undersigned and on behalf of ___________________________

confirm that we will:
1. Carry out works efficiently and strictly in accordance with requirements of the Jordan
safety Regulations & Arabtec safety guidelines applicable to the site.
2. Carry out a Risk Assessment (where applicable) for the works that we will be engaged
in and detailing the safety provisions required.
3. Safety Method of Work Statements (where applicable) are produced in advance and
submitted to Arabtec safety team for approval before work can commence.
4. Appoint a Safety Manager/Engineer to ensure that works are carried out in accordance
with the works safety procedures.
5. Set-up and maintain an efficient and adequate system of first aid and welfare facilities
for employees unless shared welfare facilities are provided by Arabtec / others.
6. Maintain good, safe working relationships with Arabtec Employees, Client/
Consultants personnel and fellow Sub-Contractors.
7. Fully participate in the site safety committee to improve the overall safety practices.
8. Report all hazards and accidents in accordance with the construction site safety
guidelines.
9. Ensure that all workers are inducted; work is carried out by trained/ competent
operatives with needed PPEs and properly supervised.
10. Reprimand and discipline any employees who are careless in regard to their own or
others safety. (Note: Arabtec will not hesitate to instruct the removal from works of
offenders)
On behalf of __________________
___________________________ _________________________
Employee Name Employee Signature
Title: _______________________ Date: ____________________
Form # 10018- Rev 0-Jun 09

Received: Location:
COSHH RISK ASSESSMENT FORM
Due for Review: Ref Number:
Risk Assessment Title:
SUBSTANCE INFORMATION
Are any of these substances: Are any of these substances
Description of Procedure Location
(See warning label on packaging or MSDS) hazardous to health:
(F+)
Extremely Flammable
Flammable (F)
Highly
Explosive (E)
Oxidising (O)
Very Toxic (T+)
Toxic (T)
Corrosive (C)
Harmful (Xn)
Irritant (Xi)
Environment (N)
Dangerous for
skin
When in contact with
eyes
When in contact with
When breathed in
When swallowed
/ Teratogen
Carcinogen / Mutagen
CAS Registry
Substance(s) Used Number Quantity
(if exists)
CAS Registry
Products created and waste material Number Quantity
(if exists)
Chemical Reactions: Any material or chemical these If any substance(s) are extremely
substance(s) must not come into contact with?  flammable state lowest flash point 
PROCESS INFORMATION
Brief description of process and controls in place minimise risk
Form # 10019-Rev 1-April 12

If appropriate, work only to be
carried out by these named people 
CONTROL MEASURES
Can less dangerous substances or If so, why are they not
processes be used?  Yes / No
being used? 
Do any substances used have Personal Protective
Workplace Exposure Limits (WEL)?  Yes / No If so, give details below  Engineering Controls
Equipment (PPE)
Groups at risk
Short Term Exposure Limit
Substance TWA (8 hours)
Other:
Other:
Goggles / Facemask
(STEL) (15 min)
Protective clothing
Open Bench OK /
Ventilation (LEV)
Total enclosure/
Fume Cupboard
Subcontractors
Local Exhaust
Respirator
Glove Box
Suppliers
Workers
Visitors
Gloves
None
Staff
Controls measures in place to minimise risk 
Additional info (e.g. type of gloves) 
OTHER PRECAUTIONS AND EMERGENCY MEASURES
First Aid: What Action should be taken if substance(s) are:  How should an accidental release / spillage be dealt with? 
Swallowed:
In contact with Skin:

Fire Precautions: What actions will be taken in the event of a fire involving these substance(s)? 
In contact with Eyes:
Disposal: How should these substances be disposed of (or not disposed of)? 

Breathed in:
Sources of Information
(e.g. Suppliers MSDS) 
Is heath surveillance required? Yes / No Is training required for this process? Yes / No
DECLARATION REASSESSMENT
Assessment Name: Signature: Date: Date for reassessment Review Date Reviewed By
completed By:
Name: Signature: Date:

Supervisor:
Project Safety Name: Signature: Date:

Manager/
Engineer/
Officer:

ARABTEC CONSTRUCTION - SAFETY DEPARTMENT
Crane Set-Up Checklist
Site: Date:
Crane Company Capacity

Crane Operator Type
Licence / Permit Crane I.D.
No. Requirements Yes No Comments

1 Rigging study correct and approved
2 Rigging crew competent
3 PPE worn by rigging crew
4 Trained banksman present
5 Ground suitable for the lift
6 Crane level
7 All outriggers extended
8 Outrigger blocks in use
9 Wheels off the ground
10 Crane slew area barrier in place
11 Valid test certificates available
12 Correct crane load chart available
13 Tag lines use
14 Weight of the load known
15 Loose lifting equipment suitable
16 Safe load indicator fitted / working
17 Slinging / rigging correct
18 Crane operator competent
Details of the person(s) conducting the check

Name(s) Signature(s) Company
HSE ENGINEER
RIGGING SUPERVISOR
ENGINEER IN CHARGE
Form # 10020- Rev 0- Jun 09

ARABTEC SAFETY DEPARTMENT
HEALTH & SAFETY AUDIT REPORT
Date: Time:
Auditor: Location:
Notes :
 For aspects of the audit/inspection, which are not relevant to this particular audit, insert
N/A in the right hand column.
 For any other factors of safety which are relevant to this particular audit but are not
included in the standard audit format, they may be included by the Auditor in part: 14 on
page 6 of 6.
1 Lifting and vertical transportation equipment : Score

Achievable Achieved
a. Condition of carnage and hoisting equipment. 35
b. Valid certification of carnage and hoisting equipment. 30
c. Competency of crane and hoist operators. 25
d. Effective use of trained banksmen. 20
e. Use of outriggers and floats. 15
f. Equipment storage issuing and receiving. 5
Total
130
2 Scaffolding and formwork support systems : Score

Achievable Achieved
a. Equipment selection, suitability and stability. 30
b. Use of toe boards, handrails and adequate bracing. 25
c. Use of barriers and warning signs. 20
d. Provision of safe access and egress including ladders. 10
e. Use of scaffolding tag system or similar method. 10
f. Ground level conditions and safety arrangements. 5
Total
100
Page 1 of 5 Form # 10024- Rev 0- Jun 09

3 Safety management systems : Score
Achievable Achieved
a. Availability of approved site safety manual. 30
b. Posting of Arabtec-EEC JV Construction’s safety policy. 20
c. Operation of an effective training programme. 15
d. Displaying emergency telephone numbers. 15
e. Emergency evacuation procedures in place. 10
f. Health and safety record keeping and related documentation. 5
g. Project safety notice board on view. 5
Total
100
4 Staff commitment and attainment : Score

Achievable Achieved
a. Training, safety meetings and follow-up. 25
b. Senior staff. 20
c. Senior Engineers. 15
d. Site Engineers. 15
e. Foremen. 15
f. Chargehands. 10
Total
100
5 Welfare facilities and provisions : Score

Achievable Achieved
a. Eating areas. 25
b. Toilet facilities. 20
c. Drinking water availability. 20
d. Wash area. 15
e. First aid provisions and availability of trained personnel. 10
f. Waste disposal provisions. 10
Total
100

6 Availability, use and condition of personal protective Score
equipment : Achievable Achieved
a. Hard hats. 14
b. Safety footwear. 12
c. Safe clothing. 10
d. Fall protection. 10
e. Eye protection. 8
f. Hearing protection. 6
g. Gloves. 6
h. Respiratory protection. 4
Total
70
7 Temporary site electrics generally and power tools : Score

Achievable Achieved
a. Temporary site electrics and use of ELCB's. 25
b. Guards fitted to power tools. 15
c. Condition of power tools. 15
d. Cutting discs fitted correctly. 10
e. Wiring and connections are suitable for the voltage being used. 5
Total
70
8 Hot work (gas cutting and electric welding) : Score

Achievable Achieved
a. Use of flash-back arrestors and check flow valves. 15
b. Condition of hoses and connections. 10
c. Gas cylinders are kept upright and secure. 10
d. Condition of gauges. 10
e. Condition of welding leads. 8
f. Cylinder caps. 5
g. Condition of earth leads. 4
h. Availability of fire extinguisher/s and their condition. 4
i. Availability and use of fire screens and blankets. 4
Total 70

9 Fire extinguishers : Score
Achievable Achieved
a. Good condition. 20
b. Correct type and size. 20
c. Personnel training. 15
d. Located correctly. 10
e. Inspected and tagged. 5
Total
70
10 Hand tools : Score

Achievable Achieved
a. Suitable for the job. 20
b. General condition. 15
c. Correct usage. 15
d. Not home made. 10
Total
60
11 Working areas : Score

Achievable Achieved
a. General housekeeping. 18
b. Use of barriers and warning signs. 14
c. Lighting. 10
d. Site access and egress. 8
e. Work access and egress. 6
f. Store and tool control. 4
Total 60
12 Control of substances hazardous to health : Score

Achievable Achieved
a. Correct use of personal protective equipment. 10
b. Controlled storage and use of substances. 10
c. Correct labelling. 5
d. Availability of material safety data sheets. 5
e. Use of correct and suitable containers. 5
f. Safety and emergency procedures. 5
Total
40

13 Plant/vehicles : Score
Achievable Achieved
a. Competency of drivers and operators. 15
b. Condition of plant and vehicles. 10
c. Back-up (reversing) alarms in operation. 5
Total =
30
Grand total =
1,000
Grand total this audit =
Audit result =
%

Arabtec Construction LLC
Health, Safety and Environment Department
CHECK LIST FOR LABOUR ACCOMODATION
Camp Location : ……………………………….. Date: ……….………..………...
Camp in Charge : ……………………………….. HSE Inspector: …………..…...
Note All legal requirements are High Risk Level.

SL. Applicability Legal Risk Level Control
Area Covered Observation Due Date
No. Yes NO N/A Y/N Low Med. High Measures
ACCESS AND EGRESS
Is there segregation between vehicles/
1
pedestrians
N
Is entry to inside camp restricted to workforce
2
only? How is this controlled
N
3 Is the entrance well lit N
4 Is the entrance free from water pooling N
GENERAL HOUSEKEEPING
Are there adequate dustbins available? Are
1
they covered
N
2 Is garbage disposed of on a regular basis? N
3 Are toilets wash areas cleaned regular? N
4 Is there adequate water for toilet and bath N
5 Are water tanks kept covered at all times N
6 Is soap and hand towels available? N
Is bathroom area cleaned on a regular basis
7
and kept dry and non slippery
N
8 Is the water tank cleaned on a regular basis Y H
Is the laundry area electrical & connections/
9
wires are in good condition.
N
10 Is the laundry area kept clean and dry N
Is the tumble dryer filters cleaned frequently to
11
prevent overheating N
1 of 6 Form # 10028 -R ev.0 Jun-09

SEPTIC TANKS
1 Is the camp on main drainage? N
2 If not are septic tanks provided? N
Are septic tanks fitted with overflow alarm if not
3
how are they prevented from overflowing
N
4 If septic tank in ground is it in a membrane? N
If above ground is it protected from being hit by
5
vehicular traffic?
N
FOOD PREPARATION AREA
1 Is the area kept clean and tidy N
Are food preparation areas cleaned
2
services.free from cracks N
3 Are signs for "No smoking" being posted. Y H
Food waste storage area is cleaned, odour free.
4
Flies area controlled
Y
H
5 All refrigerators
Floor drains are and freezers
provided are area
in sink working at Y H
correct temperatures
6
Refregierators 1c0 to 4c0
Y H
7 Are there temp gauges fitted? Y H
8 Are these temperatures recorded? Y H
The Dining and Kitchen areas have an overall
9
cleane, tidy and well maintained appearance
N
LPG cylinders are of good conditions (free of
10
damages)?.
Y
Is storage of LPG satisfactory under shed & H
outside kitchens with no flammable materials
11
nearby
Y H
12 Are Piping not perished? Y H
Are fire fighting equipment provided in kitchen
13 area? Y H
2 of 6 Form # 10028 -R ev.0 Jun-09

LIVING QUARTERS H
1 Are Ventilation working good? Y H
2 Is lighting suitable? Y H
Are Emergency numbers being posted in each
3
room?
Y H
Are emergency procedures posted in each
4
room?
Y H
Are Electrical sockets in good condition not
5
damaged & no bare wires are placed in sokets? Y H
6 Are sokects overloaded? Y H
ELCB is provided checks carried out and
7
recorded by the camp management
Y H
Filter's in A/C are cleaned on a regular basis
8
and records kept.
Y H
FIRE FIGHTING H
1 Smoke detectors fitted in all areas Y H
2 "No smoking" signs are posted. Y H
3 Is Fire Pump working? Y H
Are Fire hose reels working & "ON" all the times
4
are they free of damages & can cover all areas Y H
Adequate number of fire extinguishers
5
available.
Y H
6 Are F.Es. checked monthly records available? Y H
7 Are F.Es. re-serviced on yearly basis. Y H
Are Fire alarm working correctly tested on
8
weekly basis?
Y H
Are emergency evacuation plan with assembly
9
points.escape routes, F.Es & F.A. posted at
Y H
EMERGENCY PROCEDURES H
1 Are escape routes signed posted? Y H
Are people aware of what to do in an
2
emergency situation? Y H
Are Fire exit signs available & leuminous at all
3
the times.
Y H
Emergency lighting working and checked
4 weekly.(records kept) Y H
3 of 6 Form # 10028 -R ev.0 Jun-09

5 Emergency Telephone numbers are posted Y H
Are rescue team well aware of their
6
responsibilities in case of an emergency
Y H
7 Emergency assembly points (at least 2) Y H
Are all exit doors free of obsticales at all times
8
(minimum 2 exits at opposite sites). Y H
FIRST AID H
Is there an adequate signage for whereabouts
1
of First Aid Box
Y H
Is there a qualified First Aider on site 24 hours a
2
day
Y H
3 Is his contact number posted Y H
Does the First Aid medication list according to
4
DM recommeded it list.
Y H
Is there a First Aid Register kept and is it
5
completed correctly & update monthly
Y H
RECORD KEEPING H
1 Is there a Do's and Don't list posted Y H
2 Up to date list of room allocation Y H
3 Emergency drill are recorded Y H
4 Daily log kept Y H
5 Record of disposal of waste Y H
6 Record of disposal of sewage Y H
7 Record of Portable water delivery Y H
Prevention & maintenance schedule for A/C
8
available
Y H
9 Pest control conducted Y H
10 Visitors log kept Y H
ENVIRONMENT H
Fuel tanks (if on site) are they adequately
1 bunded? Y H
4 of 6 Form # 10028 -R ev.0 Jun-09

Are spills kits for environmental hazards readily
2
available?
Y H
Is oil used in cooking regularly changed and
3
how is it disposed?
Y H
4 Is waste segregated? Y H
ANY OTHER INFORMATION H
1 Grocary & canteen permit Y H
2 Health card for.labour in canteen& grocary Y H
3 Camp permission from DM Y H
4 Designated area for smoking Y H

CIVIL DEFENCE REQUIREMENT H
1 Camp should have 2 exits Y H
2 Corridors should be from hurdles Y H

Fire alarm control panel install in enterance of
3 camp
Y H
4 12Kg. F.Es. ABC placed at exits Y H

SUMMARY
HSE Officer / In-Charge Date:______________

Name : Signature:__________
5 of 6 Form # 10028 -R ev.0 Jun-09

6 of 6 Form # 10028 -R ev.0 Jun-09

Arabtec Construction (LLC)
HSE LEGISLATION & REGULATIONS REGISTER
Last
Sr No Issuing Authority Legislation Edition No revision Remarks
date
1 of 1 Form # 10029 - Rev 0 -Jan12

HSE COMMUNICATION REGISTER
Date of
Date Name of Person/ Organization Contact Details Description of Complaint/ Enquiry By Whom Remarks
Response
1 of 1 Form # 10030-Rev 0- Jan'12

EMERGENCY RESPONSE FLOW
ANY PERSON NOTICING
AN ACCIDENT
Attract attention of nearby Information to

persons/ Engineer / Foreman Arabtec Head Office
Incident Controller / Project HSE

Manager
Project Manager
(Name & Contact No.)
Inform Police/ Civil
Information to Client/
defense/ Ambulance after
Consultant/other
declaring Emergency
concerned
HSE Engineer/ Officer Project/ Site Engineer

(Name & Contact No.) (Name & Contact No.)
Incident/
Accident Site
Emergency declared
Gate & Traffic Control Stopping of activities and

Security Evacuation
(Name & Contact No.) Respective trade foreman
Fire Fighting Roll Call

Civil Defense Stores/ Timekeeper
(Name & Contact No.)
First-aid and Hospital/ Casualty Rescue

clearance Site Engineer, Foreman, and if
Safety Officer (Name & Contact No.) necessary Civil defense.
Male Nurse (Name & Contact No. ) (Name & Contact No.)
Detailed Report
-With correctives and preventive Other Activities- repair
Site
actionManager / Project
plan by Project HSE Project Manager to assign
Engineer
Manager/Engineer/Officer responsibilities
Form #10031-Rev 0-Jan’12

HSE VIOLATION NOTICE
INITIATOR /AUDITOR RECEIVER/AUDITEE

NAME
DESIGNATION
DEPARTMENT
PROJECT PROJECT # DATE :

NOTICE NO :
PROCEDURE / CLAUSE REF.
DESCRIPTION OF THE HSE VIOLATION: Major Minor Observation

Unsafe Act Unsafe Condition
Initiator / Auditor: Accepted By:

INVESTIGATION INTO THE ROOT CAUSE OF THE PROBLEM
Please tick the cause and then elaborate:
01 Inadequate knowledge and/or skill. 02 Lack of Supervision 03 Untrained / Inexperienced worker
04 Control measure(s) not in place 05 Inadequate Engineering or Design 06 Inadequate Inspection or Maintenance
07 Usage of wrong tools & equipment 08 Improper planning 09 Inadequate Instruction or Training
10 Legal Compliance not in place 11 Miscellaneous (Specify)
Initiator / Auditor: Responsibility:

RECOMMENDED CORRECTIVE/PREVENTIVE ACTION :
Responsibility: Agreed completion date:
CORRECTIVE/PREVENTIVE ACTION TAKEN :
Responsibility: Date:
HSE VIOLATION CLOSED-OUT SATISFACTORILY
Initiator / Auditor: Name: Signature: Date:
Form # 10032- Rev 0 - Jan 12

HSE VIOLATION NOTICE LOG
AUDIT AREA :
HSE VIOLATION DATE OF DESCRIPTION OF REPORT FOLLOW UP DATE CLOSED ROOT CAUSE REMARKS
NOTICE NO REPORT DATE OUT
Form # 10033-Rev 0- Jan'12

HAZARDOUS & FLAMMABLE SUBSTANCES
ASSESSMENT CHECKLIST
USE ONE FORM FOR EACH SUBSTANCE
Location: Hazardous /
Contractor: Flammable
Work activity: Substance
TICK APPROPRIATE BOXES
EXPLOSIVE FLAMMABLE HARMFUL TOXIC

YES YES YES YES
NO NO NO NO
IRRITANT CORROSIVE OXIDISING

YES YES YES
NO NO NO
YES NO
1 Is the manufacturer’s hazard data information sheet available?
(Please attach)
2 Has the use of each substance been established as essential to the task or function for
which it is used?
3 Have all necessary safety precautions been established for each hazardous substance
including the provision of any necessary water or ventilation systems and permit
systems?
4 Are suitable storage requirements provided?
5 Are all necessary hazard warning signs in place local to the substances in use or
being stored?
6 Are all vessels, tins, barrels, cylinders, bags, wrappings, etc., that contain hazardous
substances clearly marked and color coded for the substance stored?
7 Are all necessary antidotes or neutralizing agents/spill kits available in close
proximity to the hazardous substance?
8 Will users be given information concerning the hazard[s]?
9 Will users be given instruction & training in handling & use?
10 Has information been given to workers on hazardous substances that they use or
come into contact with and the risks that are associated?
11 Has training been given to workers on the task and the use of hazardous substances
together with training on the safety precautions and remedial actions to be taken in
the event of an accident, spillage or other dangerous occurrences?
Page 1 of 2 Form # 10034-Rev 0-Apr’12

HAZARDOUS & FLAMMABLE SUBSTANCES
ASSESSMENT CHECKLIST
YES NO
12 Is all necessary personal protective equipment available to all workers who use or
come into contact with a hazardous substance?
A. Masks / respiratory protective equipment?

B. Goggles / Spectacles?
C. Gloves?
D. Overalls / Clothing?
E. Boots?
F. Other Equipment?
13 Will exposure monitoring / control measures be necessary? [Attach]
14 Will health surveillance be necessary?
15 Is disposal covered by regulatory controls
16 Are safety precautions in place for the removal of used substances with special
emphasis on avoiding disposal through foul drainage systems?
17 Are first aid and emergency response actions clearly defined?
GIVE DETAILS OF HS&E PRECAUTIONS NECESSARY-

(If necessary attach continuation sheets)
Page 2 of 2 Form # 10034-Rev 0-Apr’12

INCIDENT / NEAR MISS (NM) Report LOG
Action
Rating Party Unsafe (#) as
Report Category (√) * Type of Closed
S. (√) Brief Description of (√) applicable Corrective /
No & Incident (Y/N)/ Remarks
No. Incident/Near Miss (NM) Preventive Action
Date Near Sub- (#) ** *** Date
Incident Min. Maj. ATC
Miss Con Act Condition Closed
* Type of Incident
1. First Aid Case (FAC) 6. Permanent Partial Disability (PPD)
2. Medical Treatment Case (MTC) 7. Permanent Total Disability (PTD)
3. Restricted Work Case (RWC) 8. Fatality (F)
4. Lost Workday Case (LWC) 9. Property Damage (PD)
5. Enviromental Incidental (EI) 10. Others (Specify)
** Unsafe Act *** Unsafe Condition
1. Failure to follow rules and procedures 8. Operating at unsafe speed (exceeding speed limits) 1. Inadequate/ Improper Access
2. Incorrect/Misuse of equipment or tools 9. Servicing equipment while power is on (No LOTO) 2. Poor Working Environment
3. Failure to use warning or Safety devices 10. Removing safety guard. 3. Failure/ Inadequate tool or equipment
4. Improper handling 11. Using defective equipment 4. Inadequate/ Defective Warning sign/Safety devices
5. Failure to wear PPE 12. Unsafe lifting (Mechanical / Manual) 5. Poor housekeeping
6. Taking short cuts 13. Distraction, teasing, horseplay 6. Lack/ Inadequate/ Inappropriate PPE
7.Operating without permission 14. Others (Specify): 7. Lack/ Insufficient training
8. Others (Specify)
1 of 1 Form # 10035- Rev 0-April 2012

HSE Orientation Training (New Employees)
Employee Name & MB #: ………………………………………………… Title: ……………………….………………………..

Project Name: ……………………………………………………………… Location: ……………………..……………………
Training Conducted By: ………………………………………..……….. Date: …………………………………………………
Description Date Initials

1. Explain the company safety program, including:
A. Orientation and policies

B. On-the-job training (TBT)
C. Safety meetings
D. Incident investigation
E. Disciplinary action
F. Safety Awards
2. Use and care of personal protective equipment(PPEs)
3. Line of communication and responsibility for immediately

reporting injuries.
A. When to report an injury

B. How to report an injury
C. Who to report an injury to
D. Filling out incident report forms
4. General overview of operation, procedures, methods and
hazards as they relate to the specific job
5. Pertinent HSE rules of the company and/ or facility/ Project
6. First aid supplies, equipment and training
A. Obtaining treatment
B. Location of Facilities
C. Location and names of First-aid trained personnel
7. Emergency plan
A. Exit location and evacuation routes

B. Use of fire-fighting equipment (extinguishers, hose)
C. Specific procedures (medical, chemical, etc.)
8. Vehicle safety
9. Personal work habits
A. Serious consequences of horseplay

B. Fighting
C. Inattention
D. Smoking policy
E. Good housekeeping practices
F. Proper lifting techniques.
Page 1 of 2 Form # 10036- Rev 0-Dec 2012

HSE Orientation Training (New Employees)
10. Employee and Employer rights and responsibilities
11. Work Permit system
12. ATC Disciplinary Policy
13. Waste Management (waste segregation, hazardous and non-

hazardous waste, waste disposal).
NOTE TO EMPLOYEES: Do not sign unless ALL items are covered and ALL questions are discussed to
YOUR satisfaction. Therefore, YOUR signatures below signifies that YOU accept the responsibility for
maintaining safe and healthy work environment during your employment with ATC
Conducted By Signature: __________________________________ Date: _____________
Employee’s Signature: ___________________________________ Date: _____________
Page 2 of 2 Form # 10036- Rev 0-Dec 2012

CONFINED SPACE ENTRY PERMIT
Permit No. MS&RA N0. Date

ENTRY REQUIRED FOR PAINTING FINISHING HOT WORKS Others (Specify) ……………………..
Section – I DETAILS OF THE PERMIT RECEIVER

Project / Section Location (s)
Permit Receiver (Engineer) Contact Number
DETAILS OF THE PERMIT Holder
Permit Holder (Supervisor) Contact Number
Section – II PERMIT VALIDATIONS
PERMIT ISSUE DETAILS Date ____________________ Time ________________ NO EXTENSION WILL BE
PERMIT EXPIRY DETAILS Date ____________________ Time ________________ GIVEN ON THIS PERMIT
This permit covers ENTRY ONLY to a confined space.
All work entailed in effecting entry and after entry shall be covered by the appropriate WORK PERMIT.
Section – III PREREQUISITE (Work May be stopped if one of the following is not complied with)
N
 for YES and X for No /X
A
 for YES and X for No /X NA
Are emergency procedures and Fire

A Atmosphere in the Confined Space Tested? K
prevention in place?
Are Method Statement/ RA
B Oxygen level is 19.5% - 23.5 %. L
communicated?
Has the toolbox talk been given by
C Will the atmosphere be monitored during work? M
supervisor?
Air intake system located free from
D Are safe access/ egress provided? N
fume?
Will any Chemicals be used in the
E Has the space been ventilated before entry? O
space?
F Will ventilation be continued during work? (LEV) P Is adequate illumination provided?
G Means of communication available? Q Harness / lifeline / tripod available?
Are electrical equipment’s and connections
H R Appropriate PPE Provided?
safe?
Have all routes of energy ingress been
I S Watcher(s) available?
isolated/Plugged and tagged?
J Will any other equipment be used in the space? T Was the space found unacceptable?
Details of Employee working 1. 4.
in the confined space 2. 5.
Name, Id.No. , Trade 3. 6.
Details of Stand-by 1. Supervisor: 3. Rescuer:
Persons 2. First Aider: 4. Rescuer:
Details of Equipment/s
and/or Material/s to be used
Details of Chemical/s to be
used
Declaration by the Permit Receiver Declaration by the Permit Holder
I_________________ representing _________________ hereby

I_________________ representing _________________
declare that I have checked the location and all the employees hereby declare that I have checked the location and all the
employees have been briefed about the emergency
have been briefed about the emergency procedure and a toolbox
procedure and a toolbox talk given on working in confined
talk given on working in confined space to ALL involved in the space to ALL involved in the activity.
activity.
Date :……/……/…… Name; ……………. Signature;…………….. Date :……/……/…… Name; ……… Signature;……………..
Page 1 of 2 Form # 10039-Rev 0-May 2014

CONFINED SPACE ENTRY PERMIT
Section IV PERMIT SIGNATORY (PM/CM)

Work shall be carried out ONLY after complying with the precautions given in Section – III of this Permit.
The permit is valid up to _______ hrs. on / / . It has to be ensured that the employee executing the Job has a copy of
the permit at all times during work. No equipment’s shall be left unattended at any time whatsoever the reason may be. No
equipment/material is allowed to be taken in the space without prior approval.
Name of the PM/CM:…………………………… Signature …………………………………. Date …….../…..…./……..

Section V SAFETY VERIFICATION
Work area was verified prior to start of the activity.
.
Name of the HSE Officer:…………………………… Signature …………………………………. Date …….../…..…./……..
PERMIT COPY DISTRIBUTION (tick appropriate boxes):

Project Manager CM/Engineer Supervisor Site HSE
PERMIT CLOSE OUT I confirm that the work area has be checked and the safety controls
Re-instated as per the requirements of this PTW.
Name of authorized Person Signature of Authorized Person Date:
Note: HSE must be copied for all Permits.
PRE - ENTRY GAS TEST RECORD

Test Results Authorized Tester
LEL Oxygen H2S CO Name MB No. Date Time Signature
Page 2 of 2 Form # 10039-Rev 0-May 2014

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INCIDENT / NEAR MISS INVESTIGATION REPORT

Location: Report No.

Category : Incident Near Miss Property Damage Environmental Incident

Property Damage/ Environmental

Details of persons hospitalised

Sr. No. Name Company Designation Name of Hospital

Details of Machinery / Vehicles involved in the incident/near miss:

Page : 1 of 6 Form # 10001-Rev.3-April-12

Location: Report No.

Category : Incident Near Miss Property Damage Environmental Incident

Property Damage/ Environmental

I-B UNSAFE ACT

II- Underlying causes

III- Type of Injury: (in case of no injury please check here □)

Page : 2 of 6 Form # 10001-Rev.3-April-12

Location: Report No.

Category : Incident Near Miss Property Damage Environmental Incident

Property Damage/ Environmental

V- Type of Injury by Cause :

VI- Describe in details the Incident/ Near Miss

Page : 3 of 6 Form # 10001-Rev.3-April-12

Location: Report No.

Category : Incident Near Miss Property Damage Environmental Incident

Property Damage/ Environmental

Explain the changes required as indicated above:

X- Actions taken to close out the report:

Report Closed - Name:

Page : 4 of 6 Form # 10001-Rev.3-April-12

Location: Report No.

Category : Incident Near Miss Property Damage Environmental Incident

Property Damage/ Environmental

Comments (If any)

Report Prepared by:

Page : 5 of 6 Form # 10001-Rev.3-April-12

REPORTING PERIOD: From: To Date:

(1) MAN HOURS* WORKED

From start (Cumulative) For the Period To date (Cumulative)

Formula Calculation Result

Total Man Days Lost X 1000000

Formula Calculation Result

No of Lost Time Incident X 1000000

1 of 3 Form # 10002-Rev 5- Dec 11

REPORTING PERIOD: From: To Date:

(5) OTHER ACTIVITIES

(6) Type of Injury by Cause :

02 Collapse of structure / Handling materials

09 Falling objects / materials 19 Others

10 Falls from height

2 of 3 Form # 10002-Rev 5- Dec 11

REPORTING PERIOD: From: To Date:

(7) Record of Last LTI

HSE Staff Name: ________________ PM's Name: ________________

Signature ____________________ Signature _________________

3 of 3 Form # 10002-Rev 5- Dec 11

LOCATION MONTH DATE

Inspected By: Page : of Form # 10003-Rev 1-Jun 09

HSE MANAGEMENT - CHECKLIST

Sl. Activities / Items to be Inspected Remarks by Safety staff

1 Availability and awareness of the

HSE Staff Name: PM's Name:

Signature ____ Signature _

Employee’s Name : ____________________________ M.B.No. :

Name: ___ Name: _

Designation: ___ Designation: _

Date of Accident_______________________Time of Accident_

I, the undersigned and on behalf of _______

Title: ___ Date: