OPERATIONS MANAGEMENT SYSTEM OMS-313/SHEM-05- FM-05/11

Third Party’S Monthly / End Of Rev. No. 0.0

Contract EHSS Report Form-11 Sep -2019
Page 1 of 9

(This format to be used in contracting company letterhead)

THIRD PARTY’S MONTHLY / END OF CONTRACT EHSS REPORT – Covering Letter

Date:
Ref. No. P.O #: _________________
Service Type: ____________

(Sabic Affiliate Name)_______________________________________

Post Box # ___________
Al-Jubail Industrial City – 31961
Kingdom of Saudi Arabia

Attention: Name of the EHSS Department Sr. Manager / Manager

Designation

Subject: THIRD PARTY’S MONTHLY / END OF CONTRACT EHSS REPORT

Respected Sir,

Please find attached the Monthly EHSS report of (Name of Third Party company) for the month of ____________.

This is for your information and necessary action.

Regards,

Name of Third Party’s Safety Officer

Designation

CC: Third Party Safety Coordinator /EHSS Function

OMS-313 (SHEM-05) Administrator

THIRD PARTY’S MONTHLY / END OF CONTRACT EHSS REPORT

 OPERATIONS MANAGEMENT SYSTEM OMS-313/SHEM-05- FM-05/11

Third Party’S Monthly / End Of Rev. No. 0.0

Contract EHSS Report Form-11 Sep -2019
Page 2 of 9

Report No.
Report Date: Report Period:
1. EHSS Performance:
Month: _________ Year to Date
Fatality
Lost Time Injuries
Restricted Work Injuries
Medical Treatment Injuries
First-Aid Injuries
Near miss, Unsafe act and Unsafe
condition

This Month Year to Date Start to Date

Man-hours without a lost time Injury:

2. EHSS Observations/ Audits/ Inspections:

A Observations/ Audits Submitted :

S# No. of safe No. of un-safe No. of un-safe
Observations/ Audits * Observations Observations/ Observations/
discrepancies discrepancies Corrected

1 Behavior Observations
2 Temporary/Portable cabin
inspection
3 Third Party Mgmt. Walk through

Total
* (Including other Third Party, focus on violation to EHSS & safe work practice)

B Regular Monthly/Weekly Inspection :

S# Date of S#
Tools / Equipments Tools / Equipments Date of Inspection
Inspection
1 Fire Extinguishers 10 Body Harness / Lanyard
2 SCBA 11 Lifting / Rigging Equipment
3 Hand Tools 12 Natural rope –Manila / Nylon
4 Power Tools 13 Ladders
5 Impact wrench 14 Cylinders
6 Crane / Forklift / Trucks 15 Tricycle
7 Pick Ups
8 Welding Machines
9 Electrical / Power cords

(Rejected materials shall be tagged immediately with a “do not use” and to be removed from the site as soon as possible)
 OPERATIONS MANAGEMENT SYSTEM OMS-313/SHEM-05- FM-05/11

Third Party’S Monthly / End Of Rev. No. 0.0

Contract EHSS Report Form-11 Sep -2019
Page 3 of 9

THIRD PARTY’S MONTHLY / END OF CONTRACT EHSS REPORT

3. EHSS Meeting:( Shall discuss Health, Industrial Hygiene, Environment besides Safety & Security)

A Supervisor EHSS Meeting: (With a Client Monthly)

Expected Number Actual Number
S# Date Topic
of Attendees of Attendees
1
2
3
4

B Third Party Employees’ Weekly EHSS Meeting:

Expected Number Actual Number
S# Date Topic
of Attendees of Attendees
1
2
3
4
5

4. EHSS Training: (conducted by Third Party)

S# Type of Training No. of Participate /Attendees Remarks
1
2

5. EHSS Rewards & Recognitions:( Criteria and system run by Third Party on monthly basis)
Cumulative at
S# Name Client ID # Group/Craft
Client service
1
2
3
4

6. Other Activities (such as Campaigns):

S# Description
1
2
3
4
5
6
7
8

7. All Chemical agents used by Third Party at site has SDS available at site : Yes Not Applicable
As per SHEM 12, SDS to be given to end user’s environmental function/ IH contact. Ensure employees’ are wearing required PPE
and taking sufficient precautions, as mentioned in SDS.
 OPERATIONS MANAGEMENT SYSTEM OMS-313/SHEM-05- FM-05/11

Third Party’S Monthly / End Of Rev. No. 0.0

Contract EHSS Report Form-11 Sep -2019
Page 4 of 9

8. Number of updated / current individual Third Party employee files available at Third Party site office.

9. Incident Report Initiated: ( Including near misses following SHEM 10)

ACTUAL
This Month Year – To - Date

Note: Third Party employees encourage to report near misses.

10. observations/ near miss/ USA/USC against Third Party

Event Type This Month Year – To - Date Remarks

Observation
Near Miss
Un-Safe Act
Un-Safe Condition

10. How many new employees Mobilized at site, this month

Client Iqama# Trade Safety Orientation

S# Name Remarks / Reason
ID # Date
1
2
3
4
5

11. How many employees Demobilized from site, this month

S# Name Client ID # Iqama# Remarks / Reason

1
2
3
4
5

12 Third Party Employee: (conducted by Third Party)

A Annual Medical check-up status:
Percentage
Total number of
Completed Number Completed Target Date
employees planned
(Plan -100%)
Dec 31

B Worker Compensation Claim:

Are there any workers compensation claims because of working at Affiliate. Yes No
If yes, Provide evidence.
13 Third Party Action Plan Status of all above: ( If applicable)
Plan Start Plan Target Percentage
Details of action plan Remarks
Date Date Completed

14. PPE Audit:

 OPERATIONS MANAGEMENT SYSTEM OMS-313/SHEM-05- FM-05/11

Third Party’S Monthly / End Of Rev. No. 0.0

Contract EHSS Report Form-11 Sep -2019
Page 5 of 9

# Finding Corrective Action Taken

Classification: Internal Use

Procedure No: SKIMS/SHEM-05 Form No: SKIMS/SHEM-FM-05/13

Page 08 of 08
Third Party’S Monthly / End of Contract EHSS Report Date : Sep 2019
Form 11 Rev. : 00

OCCUPATIONAL INJURY AND ILLNESS SUMMARY –YEAR _____

EmployeesNumber Of[B]

WorkedEmployees Hours[C]

CasesTotal Recordable[H]

casesNumber of First Aid[I]

because of LWNumber of days lost[J]

[K]

(L)

LWSeverity Rate of(M)

Severity Rate of Total(N)

incidentsNo. Of Class A(O)

incidentsNo. Of Class B(P)

incidents)No. Of Class C(Q)

incidentsNo. Of Class D(R)

incidentsNo. Of Class E(S)

Number of Recordable Cases

(SHERSHE Rate(T)
Number of restricted /

Recordable Incidence
Restricted Workday[F]
(LW)Lost Workday[E]

Medical Treatment[G]
(FTL)Fatalities[D]

job transfer days

Month[A]

Rate
Jan.
Feb.
Mar.
April
May
June
July
Aug.
Sep.
Oct.
Nov.
Dec.
TOT
AL
No. Level/Class
Days W/O Lost Time Incident
No. of Process Safety Incidents IR Goal 0.00
(Project-to-date)
Man-Hours W/O Lost Time Incident
No. of Security Incidents SHER Goal 0.25
(Project-to-date)

Recordable Incidence Rate ( Column L) = (Column H) x 200,000 Severity Rate (LW) (Column M)= (Column J) x 200,000
( Column C) Column C

SHE Rate (SHER) (Column T) = (50xColumn O) + 5xColumn P + Column Q) x 200,000 Severity of Total Days Lost (Column N)= = (Column J + Column K) x 200,000
(Column C) (Column C)

Refer to SHEM-10 for incident classification details and system requirements.

 Form 10(Page 06 of 08)

THIRD PARTY EHSS OBSERVATION/ AUDIT SCHEDULE FOR THE MONTH OF ________( Next Month)

1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3
Name of Employee 1 2 3 4 5 6 7 8 9 31
0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0

Note: Observation/ Audit Report should be submitted to EHSS department for proper distribution and follow-up

THIRD PARTY EHSS CALENDAR FOR THE MONTH OF ____________ ( Next Month)
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Classification: Internal Use

Procedure No: SKIMS/SHEM-05 Form No: SKIMS/SHEM-FM-05/13

Page 08 of 08
Third Party’S Monthly / End of Contract EHSS Report Date : Sep 2019
Form 11 Rev. : 00

IN-HOUSE EHSS TRAINING PERFORMANCE

As per EHSS Training Matrix for Long Term Third Party
FOR THE CURRENT MONTH __________

Total of Total of
employe employee
Plan Actual
es s
S. Nominee Attendee
Training Title Freq. Participants required completed
N. s (This s (This
training the
Month) Month)
(To training
Date) (To Date)
01 EHSS Orientation Once All Third Party Workforce
02 Emergency Response Plan 3 Yrs All Long Term Third Party Workforce
03 Affiliate Chemical Hazard 3 Yrs Selected Field Long Term Third Party
(SDS) Employees
04 SHEMS Introduction Once Long Term Third Party (MPTs*)
05 SHEM-08 /Permit Receiver 3 Yrs Selected Permanent Third Party.
06 Observations/Hazard Once Long Term Third Party (MPTs)
Recognition/ PBO
07 SHEM-10 - 3 Yrs Long Term Third Party (MPTs)
Accident / Incident System
08 SHEM-06 Pre-start-up SHE Once Long Term Third Party (MPTs –
reviews Engineering Third Party only)
09 SHEM-01 SHE Once Long Term Third Party (MPTs –
Documentation & control of Engineering Third Party only.)
Records
10 SHEM-03 Operating & Once Long Term Third Party (MPTs)
MTCE procedures
11 SHEM-07 Mechanical 3 Yrs Long Term Third Party (MPTs)
Integrity including Critical
Equipment
12 SHEM-05 Third Party 3 Yrs Long Term Third Party (MPTs)
Management
13 Fire watch/Standby Man/ 3 Yrs Selected Field Long Term Third Party
Flag man Training Employees
GRAND TOTAL
PERFORMANCE %

*MPTs (Long Term Third Party Management Personnel– Sr, Manager, Manager, Specialist, Supervisors, Engineers, Safety
Officers)