HEALTH & SAFETY, COVID-19 SAFETY PROTOCOLS

TO BE ADOPTED FOR CONSTRUCTION OF THE

WESLEY/CONFERENCE OFFICE BUILDING
PROJECT,RIDGE-ACCRA

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 Table of Contents
1.0 OCCUPATIONAL HEALTH, SAFETY ENVIRONMENT & QUALITY PLAN .... 1
1.1 POLICY STATEMENT ..................................................................................... 1
1.2 OBJECTIVE ..................................................................................................... 2
1.3 INCIDENT MANAGEMENT – OCCUPATIONAL HEALTH AND SAFETY ....... 2
INCIDENTS AND OR INJURIES ............................................................................ 2
1.4 TARGET - NO FATAL OR DISABLING INJURIES ........................................... 2
1.5 Definitions: ....................................................................................................... 3
2.0 HEALTH AND SAFETY COMMITTEE ............................................................. 6
2.1 Composition. ..................................................................................................... 6
2.2 Meetings. .......................................................................................................... 6
2.3 LEGAL COMPLIANCE AUDITS....................................................................... 6
2.4 Audit frequency ................................................................................................. 7
2.5 Analysis ............................................................................................................ 7
2.6 RISK MANAGEMENT...................................................................................... 7
2.7 EDUCATION AND TRAINING ......................................................................... 8
2.8 EVACUATION PROCEDURE ........................................................................... 8
2.9 Alarm ............................................................................................................... 8
3.0 ENVIRONMENTAL MANAGEMENT ............................................................... 9
3.1 ERGONOMICS ................................................................................................. 9
3.2 SAFE WORKING PROCEDURES ..................................................................... 9
3.3 PERSONAL PROTECTIVE CLOTHING AND EQUIPMENT ............................ 10
3.4 HEALTH AND SAFETY COMMUNICATION ................................................. 10
3.5 PROJECT / SITE SECURITY ........................................................................... 10
3.6 IMPLEMENTATION COSTS .......................................................................... 11
4.0 COVID-19 SAFETY PROTOCOLS ADOPTED FOR THIS PROJECT. ............... 12
4.1 Rationale ......................................................................................................... 12
4.2 Objectives ....................................................................................................... 12
4.3 Responsibilities:............................................................................................... 12
4.4 Procedure ........................................................................................................ 16
4.5 Identifying suspected patient ............................................................................. 17

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4.6 Handling suspected patient. ............................................................................... 17
4.7 CONCLUSION ............................................................................................... 19

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1.0 OCCUPATIONAL HEALTH, SAFETY ENVIRONMENT & QUALITY PLAN

Company name: China State Hualong Construction(GH) Limited

Project name: Proposed Wesley/Conference office for the Methodist Church of Ghana
at the Ambassadorial Enclave, Ridge Accra

This health and safety plan has been prepared in terms of the Occupational Health and
Safety Act 1993 (Act No 85 of 1993) and Regulations Construction Regulation 5.1.
This Health and Safety Plan will be revised as and when additions, alterations etc are
communicated to China State Hualong Construction(GH) Ltd by the Client, his
Consultant or the Architect / Designer or the conditions of the contract dictate.
According to the Construction Regulations a Health & Safety plan “means a documented
plan which addresses hazards identified and includes safe work procedures to mitigate,
reduce or control the hazards identified;”

1.1 POLICY STATEMENT

We are committed to providing a safe and healthy working environment and this
occupational health and safety plan documents the action that will be implemented.
We acknowledge that as the Principle contractor we have both a legal and moral
obligation to as far as is reasonable and practicable to develop a realistic Health and
Safety plan making due reference to the Clients as well as the Consultants Health and
Safety Specification.
We further accept that we must ensure that the relevant legislation is complied with and
that all reasonable and practicable steps are taken by all Nominated Contractors on this
project to provide a safe and healthy environment for persons to work in and that the
public are adequately protected.
An independent health and safety management team from China State will conduct a
monthly legal compliance audit to ascertain the level of adherence with statutory
requirements, company policy and rules including Occupational Health and Safety,
Environmental and Quality standards.

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1.2 OBJECTIVE
To complete the project within the budget in respect of finance and time, to an acceptable
quality and with no injuries to employees or other persons.
The specific purpose is to achieve and maintain realistic and sustainable International and
locally acceptable standards. A ZERO tolerance attitude towards incidents and non-
compliance of prescribed quality and workmanship will be adopted. Deviations will be
investigated and the appropriate corrective action shall be implemented.
NB This Specification will be imposed on all Sub-contractors and their employees
working on this project.

1.3 INCIDENT MANAGEMENT – OCCUPATIONAL HEALTH AND SAFETY

INCIDENTS AND OR INJURIES
A policy of ZERO tolerance is the target for the project.
 Every thing reasonable and practicable shall be adopted and actively implemented
to prevent any incident or injury.
 Every possible danger or hazard shall be identified, documented, analysed and the
appropriate action to mitigate and or reduce them implemented.
 The necessary training of employees shall be identified and introduced.

1.4 TARGET - NO FATAL OR DISABLING INJURIES

 Report to HSE supervisor regarding certain incidents.
 Each incident, which occurs at work or that, arises out of or in the course of his
employment that could either result in the employee’s death that he looses a limb
or part of a limb, becomes unconscious or that he is unable to continue with his
normal duties for a period of 14 days shall be reported to the related institutional
body to handle it.
 No person shall without the permission of an HSE Supervisor, in the event of an
incident described in above disturb the site.

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1.5 Definitions:
a. Accident
COID Means an accident arising out of and in the course of an employee’s employment
and resulting in a personal injury, illness or the death of the employee.

b. Occupational disease
Means any disease/conditions resulting from exposure to items either used and or
exposed to in work place.

c. Occupational injury
Means any personal injury sustained as a result of an accident.

d. Classifications:
Fatal - Where the employee dies.

e. Disabling - When an employee cannot continue to perform the duty he was employed
for.

f. Lost time incident - When an employee does not return to perform the work he was
employed for on the next normal working day.

g. Disabling Lost Time - When an employee sustains an injury on duty and does not
return to perform the duties he was employed to do on the next normal working day.

h. Medical treatment incident - When an employee sustains an injury at work and

requires medical more than first aid treatment i.e. medical, surgical, hospital or skilled
nursing services.

i. First Aid case - Where the wound is treated from the contents of a first aid box

j. Disabling Lost Time Injury Frequency Rate (DIFR)

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It is the number of disabling injuries, including a death multiplied by 1 million
(1,000,000) divided by the total number of man-hours worked by all employees on the
project for a specific month or the project to-date. It usually computed on timely basis in
ascertaining likelihood occurrence of frequent accidents at vantage areas on site hence
mitigated to arrive at a zero accident occurrences on this project sites.

DIFR = No of disabling lost time injuries x 1,000,000

Total man-hours work for the period under review

k. Recording
All incidents must be recorded on a document similar to the injury statistic form or Log
book that shall be provided on site on daily basis.

l. Investigation
The severity of the injury will dictate whom and when the investigation must be
conducted.
Where reasonable and practicable all incidents shall be investigated prior to the end on
the shift on which it occurred, reported to or his employer became aware thereof.
Fatal and serious injuries must be investigated before the end of the shift on which it
occurred or as soon as reasonably practical after the occurrence.
A team consisting of the Principle Contractor, the construction safety officer and the
health and safety representative in whose area the incident occurred shall conduct the
incident investigation.
Where an employee of a contractor is injured the contractor and the health and safety
officer for the area in which it occurred will be part of the team.
The Client or the Consultant may if they wish form part of the team.
A record of the proceeding including signed statements, the name of the person
conducting the investigation and persons assisting team members must be kept. All
photographs etc must also be kept in the health and safety file.
NB in the event of a fatal or potentially fatal incident the nearest Ghana Police team shall
be contacted.

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The scene of the incident may only be altered or disturbed with permission of an
inspector or when it is necessary to rescue a person or lives in danger.

j. Analysis
The statistics for the total project, the main contractor and Nominated Sub-contractors
shall be analysed to ascertain if there is or if any trends are developing by the Safety
officer or a competent person appointed by the Contractor.

k. Statistics
Comprehensive incident / injury statistics must be kept for the total project i.e. the main
Contractor and every contractor. The following information must be recorded and kept on
the health and safety file of the principle contractor / s and the Sub-contractor / s.
The Client or where applicable his appointed Consultant must ensure that the relevant
statistics are collected, recorded, analysed and the appropriate action instituted.
Where a construction safety officer is appointed it will form part of his duties and
responsibilities.
Statistics must be kept in the format, suggested which is attached to this document.
The following incidents shall be recorded – Fatal, disabling lost time, days lost, medical
and first aid cases and man-hours worked. Statistics for the month under review and for
the project to-date must be kept either together on one or more documents.

l. Occupational disease / conditions

These must be reported and recorded as prescribed.
Medical certificate of fitness
A medical certificate of fitness, valid for 1 year must be available on the premises at all
times for employee working on or operating the following:
 working in an elevated position,
 suspended platform,
 Cranes – mobile - tower
 Construction vehicles.

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During the process of task analyses and or risk assessment it is possible that other tasks
may indicate that a medical certificate of fitness is necessary. Other tasks include
grinding, cutting, crushing processes, painting, working with hazardous chemicals,
driving of vehicles on construction sites, performing work that generates any dust:
cement dust, soil dust, wood dust, coal dust, etc.; working in noise areas greater than 85
dB or working with any machines that generates noise greater than 85 dB, and working
on uneven surfaces.

2.0 HEALTH AND SAFETY COMMITTEE

2.1 Composition.

The duly nominated, elected and designated employees, as health and safety
representatives will serve on a health and safety committee.
The Health and safety representatives will be required to attend the health and safety
committee meetings.
The Client, Consultant and the Contractors appointed Construction safety officer are ex-
officio members.

2.2 Meetings.
Meetings will be held on the day, date, time and place as mutually agreed upon by the
health and safety representatives and management. The frequency will also be determined
by the aforementioned.

2.3 LEGAL COMPLIANCE AUDITS

Audit schedule
The attached schedule or a similar one approved by the Client and or the Main Contractor
shall be used. The person conducting the assessment shall report in writing any major
deviations observed and where reasonable, practicable the corrective action
recommended, the party responsible to take the action and a date by which such must be
implemented.

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2.4 Audit frequency
An internal legal compliance audit will be conducted monthly.
A legal compliance audit will be conducted by an external / independent auditor one
(1) per month.

2.5 Analysis
Each audit report must be tabled and discussed at the next relevant health and safety
committee meeting. The chairman shall make any appropriate comments and or
recommendations and sign the minutes.
The Client, Consultant shall be served with a copy of the minutes.
The audit of the Contractors must be consolidated, analysed and submitted to the
principle contractor and the client.
The findings will be documented, analyses and recommendations made.
Where necessary the client / agent will be consulted with to ascertain if additional
resources and or finances are required.
The action agreed on i.e. the responsible man test - and the time scheduling must be
implemented.
As the project progresses it may become necessary to increase the frequency of audits.
NB The construction safety office will assume and be appointed to perform these
functions.

2.6 RISK MANAGEMENT

The prescribed risk identification, assessment and where necessary a method statement
will be completed prior to coming on site where possible.
As and when additional information etc is received concerning new or additional tasks
the necessary risk identification, assessment must be conducted and approval obtained.
Risks assessed that suggest a need for a change in design or other corrective action will
be referred to the architect / designer or the client or his agent.
Employees must receive, and sign acknowledgment of having received appropriate
training, that they understood the requirement and would apply the knowledge.

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2.7 EDUCATION AND TRAINING
Induction Training
No person will work on this project, or enter or be allowed to remain on the premises
unless they have received and acknowledged in writing that they have received,
understood and accept the conditions detailed in the induction programme.
A comprehensive list of all induction training given must be kept in the health and safety
files and reported on, to management at least monthly. Training sessions must be
conducted at least weekly.
NB Occasional visitors, client, agent, architect etc must be re-inducted when significant
progress has been made on the project – risk, potential risks become apparent.
Site-specific training.
Site-specific training requirements will be identified.
Where applicable a certificate on competency must be must be available – or a certified
copy – on the site.

2.8 EVACUATION PROCEDURE

The Principle Contractors evacuation procedure shall be communicated to all employees.
All site staff will report to their assembly point - the site office.
Definition of an emergency:
An emergency is a major occurrence such as a fire, bomb threat, chemical spillage,
explosion, aircraft crash, or a natural disaster i.e. earthquake / cyclone, which could result
in injury, loss of life, or extensive damage to property and the environment.

2.9 Alarm
An audible alarm will be sounded to worn employees of an emergency and also when the
situation returns too normal.
Employee response to an alarm.
Stop working,
If you are using an electric or pneumatic tool switch it off place it on the ground and
proceed to the assembly point.
Report to your Supervisor

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Employee response to the all-clear signal.
Return to your working area and proceed with the task you were busy with prior to the
evacuation.

3.0 ENVIRONMENTAL MANAGEMENT

Pressure on natural resources, including land, has continuously increased, as the
population increases and likewise, awareness of the need to lessen the negative impacts
of development and construction on the environment will continue to increase.
Every effort must be made to use environmentally friendly paints and where possible
water-based.
The containers once emptied must be disposed of at an approved disposal site or returned
to the supplier.

3.1 ERGONOMICS
Ergonomics is “the study of work”. Ergonomics therefore is the Profession that studies
and analyses people at work, the work systems, and how best they fit together.
Much of the work done on Construction Sites is by its very nature an ergonomic problem,
because it requires physical work to be done above head height, and below waist level,
aggravated by constructions materials being heavy and/or inconveniently sized and
shaped, which presents further manual materials handling issues.

3.2 SAFE WORKING PROCEDURES

A programme of safe work procedures is embarked on starting with those identified
during the risk identification and assessment. Where reasonable and practicable steps
have been taken and elements of risk still remain a procedure needs to be developed.
The employees required to perform them must receive adequate training. Proof of
training must be kept and be available on the premises.
All procedures need to be documented.

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3.3 PERSONAL PROTECTIVE CLOTHING AND EQUIPMENT
PPE shall only be issued only after all reasonable and practicable steps have been taken
to remove or reduce the hazard and or potential hazards.
All items issued must be maintained in good working order i.e. serviced and repaired as
and when necessary. Items must be issued free of charge and for the personal use of the
employee. The employee shall sign acknowledgement of receipt of the items that he will
use it, them as prescribed and that he has received the necessary training in the use and
care of the items.
The Main contractor and Sub-contractors must take all reasonable steps to ensure that
PPE issued is used, worn and maintained as described.

3.4 HEALTH AND SAFETY COMMUNICATION

Minutes of all health and safety committee meetings shall, after acceptance shall be
displayed, strategically placed on a site notice board. Where appropriate, Newspaper
clipping may be used during “tool box” talks and induction training.
Any change in company policy or legislation the may affect employees must be
communicated to employees as soon as is reasonable and practicable.

3.5 PROJECT / SITE SECURITY

Barricading and maintenance
Adequate and suitable solid barricading shall be erected and maintained to prevent
unauthorised entry as well as to control access onto and off the site.
Suitable information signs must be strategically positioned.
They will include but not be limited to the following – No unauthorised entry, all visitors
must report to the Site office, personal protective clothing / equipment must be worn etc.
NB Project / Site management are responsible for all activities taking place on the
premises, and people who enter onto or who are allowed to remain on the site.

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Access control
The Client is responsible for the access to and egress from the construction area.

3.6 IMPLEMENTATION COSTS

The cost of implementation should include but are not limited to the following:

a. Administration
Project registration,
Occupational health and safety plan and file,
All assignments, appointments and designation,
Risk identifications and assessments and Logbooks and registers,
Health and safety committee meetings and minutes

b. Training and Education

Induction training and badges,
First aid,
Health and safety representatives
Others

c. Legal compliance audits and reports

Monthly or as required by the client.

d. Personal Protective Equipment and Clothing

e. Other
Site-specific requirements are to be specified.

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4.0 COVID-19 SAFETY PROTOCOLS ADOPTED FOR THIS PROJECT.
4.1 Rationale
As part of China States` health and Safety measures to ensure a Zero health risk related
issues on this project, our health and safety team has undertaken the under listed
measures and protocols to ensure all of our site staff are exempted from not only site
injuries and accidents but also the current COV-19 pandemic related cases that may arise
at the project site.
Construction processes are dynamic with significantly varying number of workers on a
construction project site from day to day. The workers coming from diverse
environments and working closely together increases the risk of exposure to COVID-19,
Construction activities on this site shall involve earth work, procurement of materials and
supplies and their storage, construction work done by masons, steel benders, electricians,
carpenters, plumbers, painters, supervisors, managers and security personnel hence the
need to take into consideration the following.

4.2 Objectives
The two (2) main objectives for considering this protocols are as follows:
 To provide guidelines for the workers involved in construction work during the
ongoing epidemic of COVID-19.
 To provide the safety measure to be implemented at the construction site having a
dusty environment, continuous flow of different materials and make shift type of
arrangements for storage, food and sanitation, calls for implementation of COV-
19 safety precautions at the very basic level of personal hygiene only.

4.3 Responsibilities:
i. Site Managers
Without prejudice to the following, all possible and prescribed actions shall be taken at
the project site, as should facilitate the health of all life present at the site.
 As indicated in the Contracts Preliminaries, we shall make proper arrangements
for uninterrupted building services including but not restricted to electricity, fuel,
water supply, water disposal and sanitation, communications links, washrooms

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 with hand hygiene and shower facility and with proper and adequate supply of
soaps and disinfectants.
 Additional sanitary measure is to be implemented at the work location, including
but not limited to hand washing protocols, hand sanitizer stations, and provisions
of disinfectant wiping products.
 We shall ensure our workers do not use biometric attendance machines if any or
crowd during attendance, entry or exit to the premises of the construction site.
 We shall ensure the availability of the thermal gun at the entry and exit of the
construction site and no worker should be allowed without getting his/her
temperature checked.
 The Site manager shall maintain a register of all workforce including contact
details, national ID number, phone number and addresses of all present at the site
in case a follow up or tracing and tracking of contacts is required at a later stage.
 China State shall develop the employee roaster to decrease the number of people
on the site every day and split the shifts of the workers in morning and evening
with limit of each shift to 8 working hours.
 Every worker must change into standard working attire at the time of
commencement of duty and change back to their regular dress after taking shower
when their duty hours’ end.
 In addition to all other locally recognized safety precaution for construction
workers and other stuff, every individual must be provided with a face mask. We
shall ensure that everyone during his or her presence at the site continues to wear
the mask. Face mask shall be replaced as and when soiled or otherwise removed.
Outer surface of face mask must not be touched with hands.
 Non-essential work trainings must be postponed avoiding gathering of people.
 We shall ensure the physical distance by creating more than one route of entry
and exit to the site.
 Proper training shall be given to the workers to inform the construction manager
(or authorities) if they have one or more symptoms of disease as mentioned in
section 5 below.

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 All incidences of appearance of the symptoms of COVID-19 shall be immediately
communicated through e-mail or else, to the designated health facility, and the
sick worker shall be transported to the health facility for further advice and action.
The site manager must establish a link with a nearby healthcare facility with
arrangements for quick transportation of workers in case of an emergency.
 We shall persuade the workers to inform the authorities for their safety and of
other if they observe any signs and symptoms in a colleague.
 We shall not allow any worker at the construction site who has the symptoms
hence referred to the right health facility for treatment.
 Awareness banners shall be mounted at vantage points about hand hygiene and
physical distancing, where you can, around the work site.
 We shall discourage site staffs from using other worker’s phones, desks, office, or
other work tools and equipment, when possible.
 We shall ensure only sanitize-able dinning surfaces shall be used, which must be
cleaned before each service. Food must be heated to a temperature to no less 70`C
before consumption and shall preferably be served in disposable utensils. If
reusable utensils are used, these must be washed with soap and water immediately
after use and stored at a safe place.
 The launch breaks and stretch breaks of the workers must be staggered to avoid
the clustering of workers. Workers must not sit at less than 2 meters’ distance
while having meals and while any other activity requiring interpersonal
communications.
 In the wake of current restrictions on transportations site managers will ensure
safe transport arrangements for worker which should not be crowded and should
have social distancing in place during the entire process from pickups till drops at
destination.
 In case of workers sleeping in at the site of construction, a safe distance of 2
meters shall be ensured in the sleeping rooms.
 A supply of safe drinking water shall be made available at the projects site and
maintained.

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  Work vehicles that are shared by multiple persons to be sanitized after each
journey by different persons (travelers and/or driver) by thorough cleansing of all
internet surfaces and external handles and touch points.

ii. Workers:
 Workers shall be made to enter their contact details in the register maintained at
the site, in case a follow up or tracing and tracking of contacts is required at a
later stage.
 They shall be made to follow hygiene practices at washrooms and shower facility
with proper and adequate use of soaps and disinfectants.
 Every worker will be encouraged to change into standard working attire at the
time of commencement of duty and change back to their regular dress taking
shower when their duty hours’ end.
 In addition to all other internationally and locally recognized safety precaution for
construction workers and other staff, every individual shall use face mask. Face
mask shall be replaced as and when soiled or otherwise removed. Outer surface of
face mask must not be touched with hands.
 Workers shall wash their hands as frequently as practicable and shall not to touch
their face with their hands during work.
 Workers shall be trained to clean and disinfect frequently touched surfaces
frequently. This includes tools, desks, phones, keyboards, toilets, faucets and
sinks.
 Everyone on the construction site must observe sneezing and coughing etiquettes.
 Workers shall maintain no less than two arm lengths between them before, during
after work at all times. They shall not make physical contact and shall be required
to maintain separate personal gears and assets which must be clearly labelled and
stored without intermix.
 Sick workers should immediately inform the site manager and must get medical
advice from nearby health center.

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  Only sanitize able dinning surfaces shall be used. Food must be heated to a
temperature to no less than 70`C before consumption and shall preferably be in
disposable utensils. If reusable utensils are used, these must with soap and water
immediately after use and stored at a safe place.
 Do not sit at less than 2 meters’ distance while having meals and while any other
activity requiring inter personal communications.
 Do not use biometric attendance machines or crowd during attendance, entry or
exit to the premises of the construction site.
 Safe transport arrangements which should not be crowded and should have social
distancing in place during the entire process from pickups till drops at destination
shall be made available to our workers.
 In case sleeping in at the site of construction, a safe distance of 2 meters must be
ensured in the sleeping rooms.

4.4 Procedure
Deliveries or Other Contractors visiting the Project site
 Non-essential visits to the construction sites shall be cancelled or postponed.
 Delivery workers or other contractors who need to visit the construction site shall
go through temperature check before entering and should be given clear
instructions for precautions to be taken while on site.
 Designate the workers with protective gears or at least gloved and mask to attend
to the deliveries and contractors.
 Make alcohol-based hand sanitizer (at least 70%) available for the workers
handling deliveries.
 We shall instruct the visiting truck drivers to remain in their vehicles and
whenever possible make use of contactless methods, such as mobile phones to
communicate with your workers.

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4.5 Identifying suspected patient
We shall encourage the workers to inform our Projects manager (or authorities) if:
 They develop any symptoms of cough, flu or fever.
 They have been exposed to someone suspected or confirmed with COVID-19.
 They have met someone who has a travel history of COVID-19 endemic country.
 They have travelled in last couple of days or plan to travel soon.

According to WHO, People with COVID-19 have had a wide range of symptoms
reported ranging from mild symptoms to severe illness. These symptoms may appear 2-
14 days after exposure to the virus:
 Fever
 Cough
 Shortness of breath or difficulty breathing
 Chills
 Repeated shaking with chills
 Muscle pain
 Headache
 Sore throat
 New loss of taste or smell

4.6 Handling suspected patient.

Persons who have been identified as having potentially been exposed to the virus must
not enter or remain at a workplace. Such person must report local authorities and
suspected person must be transported immediately to nearest designated health center.
 While transporting the patient, both the patient and the driver should wear
surgical masks, if available. The masks should cover their noses and mouths and
they should avoid touching the masks and their faces.
 The patients shall sit as far as possible from the driver (right hand back seat)
 No one other than the driver and the patient shall be made to ride in the vehicle.

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 During transport, vehicle ventilation shall be a non-recirculated mode to
maximize air changes that reduce potentially infectious particles in the vehicle.
 We shall consider opening the windows next to both the driver and the patient to
improve ventilation.
 Do NOT make any stops along the way.
 After the patient leaves the vehicle, it would be thoroughly disinfected.

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4.7 CONCLUSION
This Health and Safety Plan and COVID-19 Protocols has been developed and after
negotiation with the Client and lead Consultant accepted.
This approved plan will be made available to the Client, Lead Consultant and other
Nominated Contractors on this project prior to their commencing construction work on
site.
We the undersigned do hereby acknowledge receipt of, understand and accept the
contents of this Health and Safety Plan as well as the Covid-19 Safety protocols.

Client

Name Signature Designation

__________________
Date

Principle Consultant

Name Signature Designation

__________________
Date

Contractor

Name Signature Designation

__________________
Date

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