Monthly HSE statistic Return Rig:

Month/ YEAR:
F: HSE:11
ONSHORE
JOHN ENERGY LIMITED

Distribution: GM(OP), M.R, QHSE CO-RDINATOR AT HO.

Name of the site: Total Man-Hours for month:

Man- hours for others: Man-hours for JOHN:

Number of Fatalities & Permanent Disabilities in the month

Number of Lost Time Injuries in the month (LWC)
Number of Medical Treatment Case in the month (RWC)
Number of First Aid Case in the month (MTC)
Number of Near Misses in the month (FAC)
Number of Occupational Illness in the month
Number of Calendar man-Days due to sickness absence (TROI)
Number of Non- Injurious Incidents in the month which are not
included above
Number of Road Traffic Accident in the month (RTA)
Details number of drills
Fire drill camp Fire drill site Stretcher Drill H2S Drill BOP Drill

Monthly Driving Statistics

Number of journey Number of Night NO. of site Total km
plans issued Driving Permits Issues Based vehicles Driven

Miscellaneous details
Number of NO. of safe unsafe Potable water Water Total fuel
Work Permit observation/ Consumed at consumed at consumed at
issued suggestion camp. Lit/per Rig site Rig & camp.
recorded /man/ day site

Injured People absent from work or an Injured people returned to Work during the
Restricted Work during the month month, following an LTI absence or a period
of restricted work
Name(s) Certified unfit on Name(s) Certified unfit on
(date) (date)

Signed by HSE Eng.: Signed by TP: Signed by Project Manager:

Name/ Position: Name/ Position: Name/ Position:
Date: Date: Date:

Issue No:01 Rev No:00