PROJECT NAME: EHV & HVPD - COA

ELEMENT 4.1.1
INJURY AND DECEASED REGISTER
YEAR: 2021

CONTRACT ID / Iqama Date of Injury / Time of Injury / Category (Lost Time /

No PROJECT NAME NUMBER Contractor Employee Name Number Deceased Deceased Location Short Description of Incident Disable/ Deceased) Class of Accident Remarks Name of Consultant

1
380KV 0HTL IN
ALQIDDYIA 4400012358 ALHAIDER
2

3 NO INJURY HAVE BEEN REPORTED AS OF

4 January 2021
5

10

11

12

13

14

15

16

17

18

19

20

NOTE: WHERE THERE HAVE BEEN NO INJURY AND DECEASED REPORTS FOR THE MONTH, PUT A DATE IN AND LIST "NO REPORTS"

Safety Engineer / Officer Name: Signature: Date:

Project Manager Name: Signature: Date:

Page 1 of Rev.2 [08April-2019] Projects Business Unit

 PROJECT NAME: EHV & HVPD - COA
ELEMENT 4.1.1
FIRST AID INJURY REGISTER 2020
as of JAN 2012

Parts of Body
No PROJECT NAME CONTRACT NUMBER COMPANY Date Time Location Name of Injured Person Designation Brief description of First Aid
Injured

1 380KV 0HTL IN ALQIDDYIA

4400012358 ALHAIDER
2

3
NO FIRST AID HAVE BEEN REPORTED AS OF
4
JAN 2012
5

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24
25

26

27

28

29

30

31

32

33

34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100

Signature: Date:

Signature: Date:

Rev.2 [08April-2019]
Remarks Name of Consultant
Projects Business Unit
 ACCIDENT REPORT

PROJECT NAME: EHV & HVPD - COA

ELEMENT 4.3
ANALYSIS OF INJURIES: PART OF BODY (2020)
as of JAN 2012

BODY PARTS / MONTH OF Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 TOTAL

EYES 0

HEAD & FACE 0

ARMS 0

TORSO 0

BACK 0

HANDS & FINGERS 0

LEGS 0

FEET 0

OTHERS: 0

1) 0

2) 0

TOTAL 0 0 0 0 0 0 0 0 0 0 0 0 0

Safety Engineer / Officer Name:_____________________ Signature:_________________ Date:__________________

Project Manager Name:_____________________ Signature:_____________________ Date:__________________
 PROJECT NAME: EHV & HVPD - COA
ELEMENT 4.1.1
NEAR MISS REGISTER 2020
as of JAN 2021

No PROJECT NAME CONTRACT NUMBER COMPANY Date Time Location / Department Description of Incident Near Miss Classification Category (Struck by, Caught in, Status (Open / Close) Report Compiled
(Low / Medium / High) Fall from Heights, etc.) (Y / N)

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28
29

30

31 380KV 0HTL IN ALQIDDYIA 4400012358 ALHAIDER

32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51

52

53
54
55

56

57

58

59

60

61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
 87
88
89
90
91
92
93
94
95
96
97
98
99
100

NOTE: WHERE THERE HAVE BEEN NO NEAR MISS REPORTS FOR THE MONTH, PUT A DATE IN AND LIST "NO REPORTS"

Safety Engineer / Officer Name: Signature: Date:

Site Manager Name: Signature: Date:

Page 1 of Rev.2 [08April-2019]

Remarks Name of Consultant
Projects Business Unit
 PROJECT NAME: EHV & HVPD - COA
ELEMENT 4.5
DAMAGED INCIDENT REPORT
YEAR: 2021

Category (eg. Property, Fire,

No PROJECT NAME CONTRACT NUMBER COMPANY Date of Incident Vehicle, Near Miss, Location / Department Class of Incident (Major / Description of Incident Root Cause of Incident Investigated by Date Investigation Date Investigation
Med / Minor) Initiated Closed Out
Environment, etc.)

1 380KV 0HTL IN ALQIDDYIA

4400012358 ALHAIDER
2

3
NO DAMAGED REPORTED AS OF 31ST OF JAN
4
2021.
5

10

11

12

13

14

15

16

17

18

19

20

NOTE: WHERE THERE HAVE BEEN NO DAMAGED INCIDENT REPORTS FOR THE MONTH, PUT A DATE IN AND LIST "NO REPORTS"

Safety Engineer / Officer Name: Signature: Date:

Project Manager Name: Signature: Date:

Page 1 of Rev.2 [08April-2019]

Remarks Name of Consultant

Projects Business Unit

Administration Project Name Contractor Name
‫اإلدارة‬ ‫المشروع‬ ‫المقاول‬

380KV 0HTL IN ALQIDDYIA ALHAIDER

No. of Fatality No. of Loss Time Injury No. of Medical Treatment
‫عدد الوفيات‬ ‫عدد إصابات العمل‬ ‫عدد إصابات العالج الطبي‬

0 0 0
‫‪No. of First Aid Injury‬‬
‫عدد إصابات اإلسعافات األولية‬

‫‪0‬‬