MONTHLY SITE HSE PERFORMANCE REPORT DOCUMENT NUMBER

Last Reviewed: REVISION: 01 R-001

2016 July 25

* Mandatory reporting fields 29 Day of November 2021

*Project Name/Number: Engen IVD Project

*Client: Engen
*SUB – CONTRACTOR
Keaf Kaefer
COMPANIES:
Contacts: Name Contact Number

*Construction Manager Mark King 082 497 4433

*Site HSE Officer Ravelle Jacquire 073 478 1179

*Client HSE Representative Zwelethu Mbuyazi 072 524 4784

*Project Manager: Storme Wilson 079 0325 091

MONTHLY HS&E PERFORMANCE

LAGGING INDICATORS Monthly Year to
Total Date LEADING INDICATORS Monthly Year to
Total Date
*Near Misses (#) 0 1
22 53
*First Aids (#) 0 0 Toolbox Talks
2 3
*Medical Treatments (#) 0 1 Safety Meetings
4 70
*Lost Time (#) 0 1 Orientations/Inductions
55 61
* Recordable (#) / Fire 0 1 Inspections / Observations
0 1
*Damage to Property 0 0 Corrective Actions completed
*Restricted / Modified Work
Days
0 0 Other:

*Reportable Environmental 0
Incidents (#)
0 Other:

*ET Hours Worked (Regular) 3818.00 HRS 8097.25 HRS

*ET Hours Worked (Overtime) 58.75 HRS 58.75 HRS
* Sub-Contractors Hours
Worked 3322.00 HRS 5002.00 HRS
*Total Exposure Hours Post
LTI 7198.75HRS 13158.00 HRS
ET Regular HRS+ET OT + Contractors
HRS

Total HRS for the Project to

date 72841,18 HRS
*ET Total Workforce Head
Count 29
*Total Sub-Contractor Head
Count 33
*Total Exposure Head Count
ET Head Count + Sub-Contractor 62

REPORT APPROVERS

*DESIGNATION *SIGNATURE

R-001-REV.01-Montly Site HSE Performance Report Page 1 of 3

*Report Completion Instructions
Reports to be approved by the Site Construction Manager & HSE Officer. All Reports must be submitted by 10h00 on the last business day of each
month.
 MONTHLY SITE HSE PERFORMANCE REPORT DOCUMENT NUMBER

Last Reviewed: REVISION: 01 R-001

2016 July 25

*CONSTRUCTION SITE MANAGER: Mark King

*SITE HSE OFFICER: Ravelle Jacquire

*Please note – that for all accidents & incidents reported in above table– submit separate Incident Report and closed out Investigations Reports accordingly.
HSE Systems

Systems Changes Type/Reference Description Action Items

Closed Out
Y/N
Client/Site Specific None Done for Month
Legislation
Non-Conformance Type/Reference Description Action Items
Closed Out
Y/N

Audits Audit Type Comments/Result/Score Action Items

Internal/External Closed Out
Y/N
Systems None Done for Month Awaiting Client to schedule the audit date
Legal None Done for Month Awaiting Client to schedule the audit date
Site Engen IVD
Other

HEALTH
MEDICALS Monthly Total YTD

Occupational health cases 0 0

Pre-employment medicals 1 1
Baseline assessments 0 0
Periodic medicals 0 20
Exit medicals 0 0
Transfer medicals 0 3
Unfit for work cases 0 0
IOD Cases 0 0

TRAINING
TYPE OF TRAINING Total INTERNAL EXTERNAL

SHE Rep 0
Fire Fighting 0
First Aid 1
Confine space 25
Working on heights 25
Safety/Fire Watcher 0

R-001-REV.01-Montly Site HSE Performance Report Page 2 of 3

*Report Completion Instructions
Reports to be approved by the Site Construction Manager & HSE Officer. All Reports must be submitted by 10h00 on the last business day of each
month.
 MONTHLY SITE HSE PERFORMANCE REPORT DOCUMENT NUMBER

Last Reviewed: REVISION: 01 R-001

2016 July 25

Client Site Specific Training 32 4

Internal Training [Procedures etc.] 32 4
Internal Training - COVID -19 Awareness training 32 4

R-001-REV.01-Montly Site HSE Performance Report Page 3 of 3

*Report Completion Instructions
Reports to be approved by the Site Construction Manager & HSE Officer. All Reports must be submitted by 10h00 on the last business day of each
month.