TOOLBOX MEETING FORM

SUPERVISOR / FOREMAN SIGNATURE

DATE/TIME LOCATION: AREA

TASK DESCRIPTION

TOPICS DISCUSSED:
1.

2.

3.

OTHERS:

NAME & SIGNATURE OF ATTENDEES:

1. 16.
2. 17.
3. 18.
4. 19.
5. 20.
6. 21.
7. 22.
8. 23.
9. 24.
10. 25.
11. 26.
12. 27.
13. 28.
14. 29.
15. 30.

Note: Attached sheet for additional attendees.

Observed By: _____________________

Name & Signature

Disp. Supv. / Subcon HSE / Cont. HSE

A TOOLBOX MEETING REQUIRED FOR ALL LOCATIONS / JOB MOVES.

HSE-IP-01 Rev00
 PRILIMINARY SITE OHS
ORIENTATION FORM
1. Awareness about the sıte (layout, working activity, office etc.)
2. Hazard (Lıftıng operation, work at height, electricity, excavation, demolition)
etc and control measures.
3. Welfare facılıty (toılet, shelter, tea area, smoking area, clınıc etc.)
4. Report to Securıty (Report to securıty whıle entry or exıt tıme).
5. Emergency response(Muster poınt, follow signage’s, Emergency contact lıst)
6. Traffıc management ( Follow the traffic management plan and sıgns)
7. PPE (Ensure PPE whıle enter to sıte).
INDUCTION DATE TIME PAGE NO

INDCUTON LOCATION
INDUCTOR NAME
TITLE/ OCCUPATION

1. Day 2. Day 3. Day Training Efficient

No TRAINED PERSONALS TITLE/ TASK
Sign Sign Sign Efficient Evaluative / Sign

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.

HSE-IP-02 Rev.00
 Weekly Health Safety & Environmental
Report
DATE:                    
PROJECT NAME    PROJECT LOCATION   
 

WEATHER CONDITION    WEATHER TEMPERATURE   

 
WORK ACTIVITIES ON SITE 

Suspension of Work:      Yes                 No:   Reason: 

 
MANPOWER INFORMATION 
IDAP  Contractors  Subcontractors  Daily Total Man‐hour 
       
 
PERMIT TO WORK 
NO  WORK ACTIVITIES  PERMIT # CERTIFICATE #  RISK ASSESSMENT #
1         

2         

3         
 
VEHICLE INSPECTIONS 
  NO  VEHICLE TYPE  PLATE #  VEHICLE # 
1       
INITIAL 

2       
3       
4       
5       
1       
2       
3       
4       
DAILY 

5       
6       
7       
8       
9       
10       
 
TOOLBOX TALKS 

Toolbox Topic:   No of Attendee   
 
TRAINING 
No  Training Topic  No of Attendee 
1     
2     
3     
 
 
 
Is Daily safety task briefing form completed and filed? yes                 No:
Is daily site environmental checklist completed and filed? yes                 No:
Is observation cards completed, evaluated and filed? yes                 No:
 
 
 
 
 
 
INSPECTIONS OF SITE WORK ACTIVITIES 
No  Findings  Pic. #
 
1   
 
2   
 
3   
 
4   
 

   

Picture No   Picture No  
   

Picture No   Picture No  
Is There Accident‐Incident‐Near Miss events:                     Yes:                   No:    Attach the investigation report 
 
REMARKS 
 
 
 
 
 
 
 
 
Reported by:                Approved by:   
 
 
 
 
 
 
HSE-IP-03 Rev:00 

Page 2 of 2 
 ACCIDENT / INCIDENT 
INVESTIGATION REPORT
Personal Information
Employee Name: Badge Number: Nationality:

Age: Experience(Total Months): Supervisors Name:

Craft: Body Part Injured: Employee Task:

Description of Incident :
Date of Incident : Time of Incident :

Incident Location:

Brief Description of the Incident :

Type of Incident
Fatality Environment Property Damage
LTI(Lost Time Injuries) Fire Security
RWC(Restricted Work Case) MVA(Motor Vehicle Accident) NAD(Natural Disaster)
MTC(Medical Treatment Case) NM(Nearmiss) N/A
FAC(First Aid Case)

Immediate Causal Factor

Not following Procedures

Using incorrect, deffective or damaged tools / equipment

Safety Devices / guards not secure or removed, or PPE not used

Inattention, lack of awareness or poor decision / judgement

Horseplay / Violence
Guards or PPE did not work correctly

Environmental (fire, noise, temperature, chemicals, act of nature)

Workplace environment (electrics, lighting, ventilation, restricted space, housekeeping)

Operating Equipment without Authority

Inadequate or Excessive Illumination

Improper Physical Effort /Act

Other

Basic Causes

Lack of Physical capability / condition of person

Hazards not identified on risk assessment / method statement

Lack of knowledge / training

Conflicting instructions

Poor supervision / monitoring

Poor sub-contractor

Poor engineering design

Poor planning / method statement

Poor materials used

Poor storage of materials / equipment

Poor tools / equipment used

No maintenance / servicing conducted on equipment

Policies & Procedures not enforced

Poor communication / no pre-task briefing

Other

Photographs
Accident / incident sketch including critical dimensions
Actions / Measures to be taken to Prevent Recurrence of Incident

Any other relevant documentation

Witness Statements

Equipment Inspection records

Operator Licences

Risk Assessment

Method Statement

Toolbox Meeting

Training Records

Other
Witness Statements
No Witness , Name Surname Company Duty Notes
1

Name & Signature Immediate Supervisor Name & Signature Management

Reporter Approved by

Date Date
Sign Sign

Incident Risk Assessment Measures Incident Cost

Less than $1,000
Risk Category Incident Owner
Tick

> $1,000 < $10,000

Low > $10,000 < $100,000

Medium > $100,000 < $1000,000

High Greater than $1000,000

HSE-IP-04 Rev:00
 TRAINING ATTENDANCE HSE

TRAINING NAME WORK AT HEIGHT

TRAINING DATE 01.08.2017 TRAINING TIME 1 HOUR PAGE NO 1/1

TRAINING LOCATION HEAD OFFICE 1
TRAINER NAME KHALID KHAN
TITLE/OCCUPATION MANAGER HSE
EFFICIENT ASSESMENT DATE 08.08.2017

1.Day 2.Day 3.Day Training Efficient

No TRAINEE TITLE
Sign Sign Sign Efficient Evaluative / Sign

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Following criteria are attended while evaluating to training efficient:
1. Use of information’s after training
2. Answers to questions in the Training Assessment Form
3. Viewpoint and own interpretation of personals
4. Observations during the internal audits and daily controls.
Training Efficient
√: Active
X : Inactive
? : Not measured yet
Explanation:…………………………………………………………………………………………………………………………………………………………………………………………….
Effectiveness of training is evaluated min. 2 months later from the training date.
2 Effectiveness of training will be evaluated one month later from the beginning of the related studies if any study about training has not been done.
The reason must be explained if an effectiveness of training could not be evaluated yet.
If an exam has been done after training, effectiveness is evaluated according the result of the exam.
Training effectiveness of workers is evaluated at least within one week at site.
Opinions of the foreman and Engineer.

HSE-IP-05 Rev00
 HEALTH , SAFETY & ENVIRONMENT AUDIT 
CHECKLIST
PROJECT NAME  Satisfactory ‐ 100%
PROJECT MANAGER Scoring ; Improvement Required ‐ 70%
DATE Immediate Action Required ‐ 40%
Persons carrying out the Audit  86~100% ‐ G(Good) : Satisfactory
LEADER :  Grade ;  61~85% ‐ F(Fair) : Improvement Required
MEMBER :  0~60% ‐ P(Poor) : Immediate Action Req.
AUDIT ELEMENTS  G F P REMARKS
HEALTH & SAFETY

I. HSE SYSTEM (50)
1. HSE PLAN & PROCEDURE (20)
a) Establishment of Site HSE Plan & Procedure(8)
b) Notice of Site HSE Policy & Target (3)
c) Risk Assessment & Job Safety Analysis (JSA)(3)
d) Application of Permit to Work(3)
e) Filing System (Documentation)(3)
2. HSE ORGANIZATION (4)
a) HSE Organization(2)
b) HSE Allotment & Mob / Demobilization Plan(2)
3. HSE TRAINING (10)
a) HSE Training Plan & Induction(5)
b) Training Course & TBM(5)
4. MEETING & INSPECTION (4)
a) HSE Meeting & Follow up(2)
b) Regular Inspection(2)
5. STATISTICS & REPORTING(4)
a) Analysis of Accident Statistics(2)
b) HSE Record & Reporting(2)
6. INCENTIVES & DISCIPLINARY ACTION (4)
a) Incentives & Disciplinary Action Program(2)
b) Evaluation of Section & Subcontractor(2)
7. EMERGENCY PREPAREDNESS (4)
a) Organization of ERT&Scenario/Drill(2)
b) Fire Fighting Facilities & Status(2)
II. IMPLEMENTATION (50)
1. PERSONAL PROTECTIVE EQUIPMENT(PPE) (6)
a) Standard of PPE Provision(2)
b) Wearing PPE(2)
c) PPE Control Status(2)
2. WORKING AT HEIGHT (6)
a) Harness, Life Lines, Nets(2)
b) Access & Working Platform(2)
c) Handrails, Toe Boards, Opening Protection(2)
3. SCAFFOLD (6)
a) Scaffolding Structure & Components(2)
b) Access & Egress(Ladder)(2)
c) Tagging System & Inspection(2)
4. EXCAVATION & CONFINED SPACE (3)
a) Safe Slope & Support (Block, Barricade)
b) Access & U/G Services Protection
c) Inspection (Testing & Monitoring)
5. DRIVING & EQUIPMENT CONTROL (3)
a) Driver & Operator Control (License, Certificate)
b) Registration of Heavy Equipment
c) Inspection (Regular, 3rd Party)
6. LIFTING (6)
a) Lifting Equipment Certificate & Load Test(2)
b) Control of Lifting Tool (Lifting Jig, Beam etc.)(2)
c) Rigger & Operator Control(2)
7. COLOR CODING (5)
a) Subject of Color Coding & Register(2)
b) Inspector (Competent Person)(1)
c) Inspection (Cycle, Procedure)(2)
8. GAS CONTROL (3)
a) Gas Cylinder Storage (Cover, Ventilation, Signs)
b) Flashback Arrestor & Fire Blanket/Extinguisher
c) Handling (Carrier, Regulator, Gauge, Hose etc.)
9. ELECTRICAL SAFETY (3)
a) PDP Control & Earthing
b) Safety Device (ELCB, Insulation, Guard etc.)
c) Cable / Plug / Socket Protection (U/G & O/H)
10. MSDS & COSHH (3)
a) MSDS/COSHH List
b) MSDS/COSHH Training
c) Notice of Precaution
11. RADIOGRAPHY (3)
a) Storage of Radioactive Sources
b) Handling of Radioactive Sources
c) NDT Register & Monitoring
12. HEALTH & MEDICAL (3)
a) Site Clinic Operation
b) Medical Examination & Patient Control
c) Local Disease, Drug & Alcohol Control
13. HYGIENE (3)
a) Kitchen Hygiene (Test, Cleaning, Storage)
b) Accommodation Hygiene (Fumigation,inspection)
c) Drinking Water Control (Test)
HEALTH & SAFETY TOTAL 

ENVIRONMENT

I. ASSESSMENT & SYSTEM (25)
1. ENVIRONMENTAL SYSTEM(20)
a) Environmental Management Plan
b) Environmental Organization
c) Environmental Policy & Target
d) Environmental Improvement Program
2. ENVIRONMENTAL IMPACT ASSESSMENT (5)
a) Environmental Impact Assessment & Follow up
II. IMPLEMENTATION (65)
1. ENVIRONMENTAL TRAINING (10)
a) Training Plan & Record
b) Emergency Preparedness (Scenario, Drill)
2. LEGISLATION&REQUIREMENT (10)
a) Local Environmental Legislation
b) Client Environmental Requirement
3. WASTE MANAGEMENT (20)
a) Classification of Waste
b) Segregation of Waste (Storage, Sign, Cleaning)
c) Disposal Record (Agent, Quantity, Costs)
d) Monitoring & Recycling
4. WATER QUALITY CONTROL (10)
a) Waste Water Disposal
b) Sewage Effluent Measurement
5. AIR & NOISE CONTROL (15)
a) Prevention of Air Pollution (Construction, Access Road)
b) Noise & Vibration Control
c) Housekeeping Operation & Others

III. INSPECTION & MEASURE (10)

1. OBSERVATION&MEASUREMENT (5)
a) Environmental Inspection & Audit
2. NONCONFORMANCE&MEASURE (5)
a) Non‐conformance & Corrective Action Taken
ENVIRONMENT TOTAL

 HSE‐IP‐06 /Rev:00
 WRITE ACTIVITY HERE

Infrastructure Development Authority Punjab

Task Risk Assessment

HAZARDS INITIAL RISK Mitigation Control RESIDUAL RISK
Task/Job Health, Safety & Environment
Steps Hazard Population at Hazard Likelihood Risk List all Control Required Hazard Likelihood of Risk
Description and Risk Severity of Rating Severity occurrence Rating
Effect occurrence

Describe all Name all types of From From matrix Classif Describe fully all controls applicable for each hazard e.g. if From matrix From matrix Classify
Separate the job into hazards identified personnel at risk. matrix identify y risk PPE is used as a control it must be specifically described. identify identify risk rating
individual tasks and and their effects for Remember to identify Likelihood rating If a control can only be verify by documentation then it must severity with Likelihood with from matrix
record in sequence each task (from include people severity with no from be available. no controls in no controls in with each
hazard ID checklist outside the work with no controls in matrix All controls must be valid in that they reduce severity, place for each place for each hazard
and based on party who may be controls in place for each with likelihood or both hazard hazard
observations and affected place for hazard each
experience.) Note: each hazard
Additional hazards hazard
may be caused by
interaction with
other work
Site Slip trip fall , Work party,  The  access  and  egress  should  be  clear 
arrangements, injury, visitors, Office
access/egress
all the time to avoid slip trip and fall. 
staff
points  Ensure  all  connection  cables  must  be 
1 Marginal Remote LOW Negligible Remote LOW
2 2 4 near the edge of the walls around.  1 2 2
 No blockage of access with material. 
 Signs shall be posted. 

2.1

HSE-IP-07 Rev00
2.2

2.3

Prepared by: Date: Reviewed by: Approved by:

Risk Matrix Table 

PROBABILITY
1 2 3 4 5
Improbable Remote Occasional Probable Frequent
Has occured in Has occured Happens
Happens
world wide in other Has occured in several times
SEVERITY People Assets Environment Reputation construction but contruction IDAP
several times
in a year in
in IDAP
not in IDAP company IDAP

1 slight injury
Slight 1 2 3 4 5
or health Slight Effect Slight Impact
Negligible effects damage Low Low Low Low Medium
2 minor injury
Minor 2 4 6 8 10
or health Minor effect Minor Impact
Marginal effects damage Low Low Medium Medium high
3 major injury
Local Localised Considerable 3 6 9 12 15
or health
Critical effects Damage effect Impact Low Medium Medium High High
4 4 12 16 20
Single fatality
Major National 8
or permanent
Damage
major effect
Impact Very Very
Severe disability Low Medium High
high high
Multiple Extensive Massive International 5
5 fatalities Damage Impact impact 10 15 20 25
Medium

HSE-IP-07 Rev00
 FIRE EXTINGUISHER MONTHLY INSPECTION REPORT

Project No.: Project Name: Month: Inspected by:

INSTRUCTIONS:
1. CHECK FOR EXCESSIVE WEAR AND DAMAGE.
2. THE FOLLOWING SYMBOLS SHALL BE USED TO DENOTE INSPECTION FINDINGS:
+ SATISFACTORY - DEFECTIVE N/A - NOT APPLICABLE
Condition
Sr. Type of Fire Date Serial Safety Physical
Location of Gas Tag/ Label Remarks
No. Extinguisher Inspected No. Clip/ Pin Damages
Cartridge

HSE-IP-08 REV00
8

10

11

12

13

14

15

16

17

18

19

20

REMARKS ON CORRECTIVE ACTION ON DEFECT (Indicate by line number from above):

INSPECTED BY (SIGN): _____________________

HSE-IP-08 REV00
 Doc. No.HSE-IP-09
HSES Rev. 0
Page: 1 of 1
Disciplinary Procedure

HSES VIOLATION REPORT

Report No: ID No:

Name: Position:
Company: Trade:
Location: Date/ Time:

You were observed violating the following HSES Rules and Regulations as stated in the HSE
Plan & Procedures of DHQ, THQ and relevant hospitals project Sites.

Violation Details:

The following disciplinary action is:

Verbal Warning

1st Written Warning

2nd Written Warning

Final Written Warning

Dismissal/Termination

Confirmed By: Date:

Issued By: Verıfıed By:

Approved By:

HSE-IP-09 Rev00
 DAILY SITE ENVRONMENTAL INSPECTION CHECKLIST  
 
Temp °C  Contractor:

Rain mm    Area:

Moist %    Date
  Compliance
Environmental Element Findings/Remarks
Y N N/A
DOCUMENTATION/MANAGEMENT
Proof of daily site inspections conducted by Contractor        
 
Environmental Officer, weekly site inspections, audits, etc.
All documentation signed off by appropriate personnel        
SITE ESTABLISHMENT AND DEMARCATION

Site fencing and demarcation facilities remain intact        

Work areas properly demarcated and safeguarded        
WASTE MANAGEMENT

Waste separated into hazardous and non-hazardous waste as        

per Project classifications
Waste sorted and stored in the correct, color coded bins        
Waste holding area is generally tidy        
Waste manifests for hazardous wastes filled out correctly and        
records maintained on-site
Waste properly disposed as per the site hazardous and non-        
hazardous waste management plans

       

1 
 
   Compliance
Environmental Element Findings/Remarks
Y N N/A
HAZARDOUS SUBSTANCES AND HYDROCARBONS
Hazardous substances (e.g., oils, fuels and greases) inventory        
list in place
Hazardous substances are properly labeled, stored (including        
secondary containment), transported and up to date MSDS
available
Spill response material equipment on site and in order        
Spills recorded, reported and properly cleaned        
Hydrocarbons are stored in a manner that prevents from        
spilling and secondary containment is in place
Daily inventory of hazardous substances appropriately        
maintained
VEHICLE AND EQUIPMENT REFUELLING & MAINTENANCE
Conducted by dedicated staff in dedicated areas        
Areas properly protected from contamination        
Spill response equipment on site and properly used        
Spills reported, recorded and properly cleaned        
Spilled/contaminated materials/absorbent/etc. stored in        
appropriately labeled containers until disposed of
SEWAGE & SANITATION
Ablution facilities are intact        
No sewage spillages have occurred?        
Facilities are regularly serviced        
Document proof of servicing and/or disposal available        
DUST MANAGEMENT
Dust suppression equipment in working condition and readily        
available
Vehicle speed limits on unpaved roads are adhered to        

2 
 
   Compliance
Environmental Element Findings/Remarks 
Y N N/A
GROUND WATER ISSUES
Protective equipment (drip trays, spill absorbents, etc.)        
 
available on site
Protective equipment correctly used        
Accidental spills reported, recorded and immediately cleaned        
 
– contaminated soil properly disposed
NOISE MANAGEMENT
Noise incidents reported, recorded and addressed        
SUPPLY OF WATER FOR HUMAN USE
Water adequately supplied to working areas and tested        
REHABILITATION (POST - CONSTRUCTION ACTIVITIES)
Source materials for backfilling clean        
Sediment disturbance prevented        
PROTECTION OF HERITAGE RESOURCES
Procedure to report finds followed        
Works ceased and area isolated/secured        
Relevant parties informed of finds        
Staff educated on issue        
PROTECTION OF WILDLIFE
Appropriate fencing/barricades/etc. erected to prevent wildlife        
from entering construction site.
Incidents recorded and reported to relevant specialists        

3 
 
 Summary Comments

Conducted By
 
Name Signature Date

Reviewed By
 
Name Signature Date

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hse‐IP‐10 Rev: 00 

4 
 
 REFERENCE NO.:
                                                   WEEKLY SITE ENVRONMENTAL REPORT    
Contractor                                                             Area:   Date  
The Contractor shall conduct weekly inspections using this form and provide the copy of findings to the IDAP HS and Environmental Representative. The IDAP HS and Environmental Representative
may assist the Contractor with conducting the weekly site inspection in conjunction with the Contractor H S a n d Environmental Representative. Non-conformances shall be recorded in the Non-
Conformance Register and appropriate corrective actions shall be identified with suitable timeframes for resolving such.
 
  Compliance
Environmental Element Findings/Remarks
Y N N/A

DOCUMENTATION/MANAGEMENT
Proof of daily site inspections conducted by Contractor
       
Environmental Officer, weekly site inspections, audits, etc.
All documentation signed off by appropriate personnel        
Have you made any changes in your building procedures for
       
environmental reasons
Is your client aware of your commitment to improving the        
environment
SITE ESTABLISHMENT AND DEMARCATION
Site fencing and demarcation facilities remain intact        
Work areas properly demarcated and safeguarded        
WASTE MANAGEMENT
Waste separated into hazardous and non-hazardous waste
       
as per Project classifications
Waste sorted and stored in the correct, color coded bins        
Waste holding area is generally tidy        
Waste manifests for hazardous wastes filled out correctly
       
and records maintained on-site
Waste properly disposed as per the site hazardous and non-
       
hazardous waste management plans

Do you have and follow a waste minimization plan        

1 
 
   Compliance  
Environmental Element Y N N/A Findings/Remarks

HAZARDOUS SUBSTANCES AND HYDROCARBONS
Hazardous substances (e.g., oils, fuels and greases)        
inventory list in place
Hazardous substances are properly labeled, stored
(including secondary containment), transported and up to
       
date MSDS available
Spill response material equipment on site and in order        
Spills recorded, reported and properly cleaned        
Hydrocarbons are stored in a manner that prevents from        
spilling and secondary containment is in place
Weekly inventory of hazardous substances appropriately        
maintained
VEHICLE AND EQUIPMENT REFUELLING & MAINTENANCE
Conducted by dedicated staff in dedicated areas        
Areas properly protected from contamination        
Spill response equipment on site and properly used        
Spills reported, recorded and properly cleaned        
Spilled/contaminated materials/absorbent/etc. stored in
       
appropriately labeled containers until disposed of

SEWAGE & SANITATION
Ablution facilities are intact        
No sewage spillages have occurred?        
Facilities are regularly serviced        
Document proof of servicing and/or disposal available        
DUST MANAGEMENT
Dust suppression equipment in working condition and
       
readily available

Vehicle speed limits on unpaved roads are adhered to        

2 
 
 Compliance  
 
Findings/Remarks 
Environmental Element Y N N/A
GROUNDWATER ISSUES
Protective equipment (drip trays, spill absorbents, etc.)
       
available on site
Protective equipment correctly used        
Accidental spills reported, recorded and immediately
       
cleaned

NOISE MANAGEMENT
Noise incidents reported, recorded and addressed        
SUPPLY OF WATER FOR HUMAN USE
Water adequately supplied to working areas        
REHABILITATION (POST ‐ CONSTRUCTION ACTIVITIES)
Source materials for backfilling clean        
Sediment disturbance prevented as per specifications        
PROTECTION OF HERITAGE RESOURCES
Procedure to report finds followed        
Works ceased and area isolated/secured        
Relevant parties informed of finds        
Staff educated on issue        
PROTECTION OF WILDLIFE
Appropriate fencing/barricades/etc. erected to prevent
       
wildlife from entering construction site.
Incidents recorded and reported to relevant specialists        
EROSION AND SEDIMENT CONTROL 

Do you have a soil and water management plan for the site        

Do you know how to install and maintain the erosion and

       
sediment control measures in the soil and water
management plan

3 
 
 Compliance
Environmental Element Findings/Remarks 
Y N N/A
Do you have erosion and sediment control measures in
       
place before excavation starts

Are the storm water drains around your site free of pollution
       
(litter, soil, building materials…etc.)

do you check and maintain your erosion and sediment        

control measures every day
Have you retained trees and vegetation and protected them        
from being damaged
Summary Comments

Conducted By
 
Name Signature Date

Reviewed By
 
Name Signature Date

 
 
 
 
HSE‐IP‐11 Rev:00 

4 
 
 MONTHLY HSE REPORTS

Project Title:  Year:  Month:            

Monthly  Cumulative  Erdogan  DHQ 
Description PKLI MCCH QATPL REMARKS
Quantity Quantity Hospital THQ
Montly HSE Talk
HSE Training Hours
Induction trainings (No of Participants)
Total number of Safety Inspections&Audits
Total number of Safety Walks / Tours
Total number of HSE meetings
PPEs coompliance %
Total number of Drills
Total number of LTI's Cases
Total number of lostworkdays
Total number of RWI's Cases
Total number of MT's Cases
Total number of First Aid Cases
Total number of Near Miss Report
Property Damage Incident
Total number of observations
Total number of Risk Assessment /JHA/JSA
Total number of HSE Warnings
Km Driven
Monthly Man‐power
Cumulative man‐
Monthly Man‐hours without LTI hours without LTI
Cumulative man‐
Total Monthly Man‐hours hours up to date

HIGHLIGHTS:

Key Activities in Progress:

     HSE‐IP‐12Rev00
 HSSE-013 Rev1

INFRASTRUCTURE DEVELOPMENT AUTHORITY PUNJAB

Site Inspection Program

Site Inspection Program (SIP) is a process by which IDAP determine HSE performance in support of the IDAP Self Verification Plan.SIP reports to be completed electronically or manually and sent to
HSE Department.

Inspection Team: Date:

Inspection Location:

CORRECTED ON
COMMENTS Safe At Risk N/A SPOT
Stopped IR

1- Waste Management / Housekeeping YES NO

1.1 Project work areas are clean and free of excess trash, debris
1.2 Proper segregation of waste in skips being maintained
1.3 Walkways and passageways clear
1.4 Material or equipment properly stored
1.5 Electrical cords, hoses, welding leads, etc. elevated to prevent trip hazards
1.6 Scrap material free of protruding nails or other puncture hazards
1.7 Trash receptacles are provided for work areas
2 - PPE
2.1 Helmet and hi viz vest worn and maintained as required
2.2 Flame-retardant apron worn as required for welding and grinding activity
2.3 Hearing protection worn as required
2.4 Eye protection worn correctly, and in all areas
2.5 Proper foot protection worn for job performed
 HSSE-013 Rev1

2.6 Gloves worn for glove-required tasks

2.7 Face shield or goggles worn as required
2.8 Other: respirators, chemical resistant garments worn where required
3 - Excavation
3.1 Does excavation sheeting / shores protected from collapse?
3.2 Does excavation have 2 ladders or access for emergency escape?
3.3 Have design drawings for excavation been provided?
3.4 Has method statement and Risk assessment been forwarded?
3.5 Have all underground services been detected and marked?
3.6 s excavation protected by physical barriers?
3.7 Is safety warning signage being displayed?
4 - Working at Height
4.1 Body harness required and worn in a proper manner
4.2 Mini-reels with twin lanyards used and adequately secured to suitable anchorage
4.3 Perimeter guarding where necessary including netting on scaffold handrails
4.4 Tool retaining lanyards used to secure tools and equipment
4.5 Barriers erected below work area with proper signage
4.6 Access equipment used MEWPs, certified scaffolding, rope access, work basket
5 - Scaffolds and Ladders
5.1 Safe access and egress provided
5.2 Green tagged correctly and valid date within 7 days
5.3 Ladder properly secured and at angle of 4-1 and exceed the top landing by 3 ft.
5.4 Scaffold gate installed (Best practice, not legal requirement)
6 - Hoisting and Lifting Equipment
6.1 Loose Lifting Equipment has current colour code
6.2 Rigging equipment in good condition
6.3 Machinery and equipment certified and having operators lisence.
 HSSE-013 Rev1

7 - Risk Assessment process audited / checked

7.1 Risk Assessment is suitable for the task being performed
7.2 Risk Assessment control measures in place adequate for the task
8 - Tools and Equipment
8.1 Electrical cords, tools, extension leads in good condition
8.2 Tools are maintained in a safe condition
8.3 Pneumatic / hydraulic hose connections properly secured
8.4 Proper tools used for the job performed
8.5 Safety guards in place
9 - Fire Protection and Emergency Response
9.1 Flammables stored properly away from naked flame tasks
9.2 Oxygen and combustibles separated
9.3 Containers labelled as to content
9.4 Fire extinguishers properly located and inspected within one month
9.5 Flash arrestors installed on gas lines and bottles
9.6 Compressed gas cylinders properly maintained
9.7 Containment of hot work within welding screens as required
9.8 Regulator gauges properly attached and maintained in good condition
9.9 ERT alert and emergency numbers displayed on notice board
10 - Permits
10.1 Applicable permits displayed at site
10.2 Pre-task safety talk (TBT)
Procedures being followed i.e., Task Risk Assessment, Confined Space
10.3
Entry, Gas Testing, Isolations etc

11 - Barriers
11.1 Barricades installed where required and with appropriate signs attached
11.2 Goal posts are in place and in good condition.
 HSSE-013 Rev1

12 - Others
12.1
12.2
12.3
12.4

NOTE IR - Improvement Required

 MEDICINE
RELEASE FORM

I accept that I have taken the medicine which is written below and I know how to use it.
Workers
Name Surname
Department or site
Duty

No Medicine Name Quantity Amount Date Submitted by Sign SubmittedTo Sign

10

11

12

13

14

15

16

17

18

19

20

Name and Signature Reciver Name and Signature Deliverer

 CONFINED SPACE ENTRY LOG BOOK

Project
Month: Supervısor
Name:
Gas tester
Date: Remarks
O2 Level

H2S Level

Entrant log book

BADGE TIME TIME TIME TIME TIME TIME TIME TIME REMARKS
S.N. NAME OF ENTRANT
NO. IN OUT IN OUT IN OUT IN OUT

HSE-IP-15 REV:00
                      SCAFFOLDING INSPECTION            
CHECK LIST
SCAFFOLD REFERENCE NO ERECTED BY (NAME OF CONTRACTOR)

SCAFFOLD LOCATION (UNIT/EQUIPMENT NO TYPE OF SCAFFOLD (DUTY ALLOWABLE LOAD .KG/BAY
( ) LIGHT ( ) MEDIUM  (  ) HEAVY ( ) ...............
*FINDINGS RE‐INSPECTION
1 2 3 1 2 3

DATE:
SN INSPECTION ITEMS

1.0 GENERAL REQUIREMENTS
1.1 Scaffold designed by a qualified person?
1.2 Conform to the 4 to 1 base to height ratio requirement?
If not conforming ,secured to a fixed structure by use of ties?
1.3 Scaffold components of the same make /fit together without force?
1.4 scaffold components marked with the conractor's emblem and name ?
1.5 Scaffold materials in good condition ,no visible defects?
2.0 FOUNDATIONS ,BASE PLATES 
2.1 Adequate and firm footing/anchorage?
2.2 Stable base plate and with screw jack 
2.3 Proper sole plates on loose ground .Extended under two uprights?
2.4 For mobile scaffold ‐are casters with lock 
3.0 STANDART( VERTICAL TUBES /UPRIGHTS /COLUMNS/POSTS)
3.1 Plumb and braced ?
3.2 Joints not in the same lift .Arranged near ledgers as possible?
3.3 Sound materials .No visible bents or defects?
4.0 LEDGERS (RUNNERS) AND BEARERS
4.1 Securely fixed to standards with proper couplers?
4.2 Horizontally leveled?
4.3 Staggered joints and not occurring in the same bay?
4.4 Sound materials .No visible bents or defects?
4.5 Are runners interlocked and coupled to each post (standarts)?
Are the bearer attached to both posts and does the inboard coupler rest on the runner     
4.6
coupler ?
4.7 Do the ends of bearer tube have full contact with the clamp?
5.0 BRACINGS
5.1 Is transverse (or cross) bracing installed on the ends of the scaffold and 
5.2 Is longitudinal bracing installed at a 45 degree angle on both faces of scaffold?
5.3 Does the longitudinal bracing installed at a 45 degree angle on both faces of the scaffold?
If the scaffold is longer than five posts (verticals),is a new line of bracing begun at every 
5.4
fifth posts?
5.5 Is bracing installed as close as possible to the node point?
5.6 Are all brace connections secured?
6.0 TIES
6.1 Has the tie been installed at horizontal member that supports the inner and outer legs?
Has the vertical tie been installed at a height less than 4 times the minimum base 
6.2
dimension?
6.3 Have vertical ties been repeated every 610 cm (20 feet )or 
Have vertical ties been repeated every 793 cm (26 feet )or less for scaffolds wider that           
6.4
91,5 cm (3 feet) ?
7.0 COUPLERS AND FITTINGS
7.1 Proper and right couplers /fittings used?
 7.2 Couplers /fittings in good condition?
8.0 DECKINGS (BOARDS/PLANKS)
8.1 Platforms fully planked with less than 2,54 cm (1")between planks ?
8.2 All platforms at least 60 cm (3 Planks) wide?
8.3 Platform's open sides less than 35.6 cm (14")from face of the work?
8.4 Platforms extending their end supports (overhang)no more than 30,5 cm (12")?
8.5 Where planks are overlapped are they lapped over the supports?
8.6 Are planks that rest on the bearer at other than a 90 degrees angle laid first?
8.7 Are tools,materials,and debris removed from scaffold to prevent an accumulation?
9.0 ACCESS
9.1 Safe access been provided for all scaffold platforms?
9.2 Rest platform provided every 6 meters (20 feet) of scaffold height?
9.3 Ladders are clamped and positioned so as not to tip the scaffold?
9.4 Ladders are of industrial type ,in good condition ,no bents/defects?
9.5 Do rungs and steps of ladders line up vertically between the rest decks?
9.6 Is the rung spacing uniform and no more than 43 cm (16  3/4")?
10.0 GUARDRAILS
10.1 Are guardrails (top and mid rails)installed on all open sides ?
10.2 Are top guardrails installed between 92 cm to 114 cm?
10.3 Guardrails are fitted to the inside of standarts (uprights)?
10.4 Guardrails firmly clamped and secured?
11.0 TOEBOARDS
11.1 Have toe boards been installed to prevent falling objects?
11.2 Are toe boards at least 15,2 cm (6 inches)?
11.3 Toe boards are secured properly by a clamp /clip?
11.4 Toeboards are fitted to the inside of standarts
12.0 OTHERS
*Find 1‐Meeting Requirement :  "√"
2‐Not Meeting Requirement : "x"
3‐Not Applicable:"N/A"

Inspected by:
Name  Position Signature

Accept to work       To be tested  
Approved by
Name  Position Signature

HSE‐IP‐16 Rev00
 WELDING AND CUTTING SAFETY INSPECTION FORM

CONTRACTOR : ......................................................................................................................................
......................................................................................................................................
PERSON IN CHARGE : ................................................................................................................

PHONE NUMBER : ................................................................................................................

DATE : ..................... TIME : .............................. LOCATION : .....................

PERSON(S) MAKING INSPECTION : .............................................................................................................................

......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................

ITEM DESCRIPTION A B C D E

01) Are operators qualified ?

02) Screens and shields ?

03) Goggles, gloves, clothing ?

04) Equipment in operating condition ?

05) Electrical equipment grounded ?

06) Power cables protected and in good repair

07) Fire extinguishers of proper type nearby ?

08) Inspection of fire hazards ?

09) Inflammable materials protected ?

10) Gas cylinders chained upright ?

11) Gas lines protected and in good condition ?

12) Are cylinder caps in use ?

13) Fireproof blankets required for protection ?

Comments : ........................................................................................................................................

......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

NOT: A - NO, B - YES, C - ADEQUATE TIME OF INSPECTION

D - NEEDS IMMEDIATE ATTENTION , E - NEEDS CONSIDERATION

HSE-IP-17 Rev00