MONITORING SCORE-SHEET FORM FILE NO-

COMPONENT: WATER SUPPLY INTAKE/HEADWORK RECORDED BY-

STAGE: CONSTRUCTION
INSTRUCTION FOR THE PERSON FILLING THE FORM: [1] EXCELLENT = 5 (RECOMMENDATION FOR REWARD); VERY GOOD = 4 (MINOR IMPROVEMENT NEEDED);
GOOD = 3 (MAJOR IMPROVEMENT NEEDED); POOR = 2 (IMMEDIATE ATTENTION IS NEEDED); VERY POOR = 1 (WORK NEEDS TO BE STOPPED UNTIL
IMPROVEMENT IS ASSURED); CRITICAL = 0 (UNSAFE, PERSON MONITORING SHOULD CALL THE AUTHORITY TO TROUBLESHOOT AT THE SITE). [2] THE
FOLLOWING ITEM CAN BE MONITORED EITHER BY VISUAL OBSERVATION OR INTERVEWING THE LABORS/CALL OR VIEWING DOCUMENTS/RECORDS.

GENERAL INFORMATION
1. NAME OF WORK/PROJECT 2. CONTRACT NUMBER 3. DATE
                 
4. NAME OF CONTRACTOR/CONSULTANCY FIRM 5. PLACE 6. TIME
                 
7. SOIL TYPE 8. WEATHER 9. EXCAVATION DEPTH 10. AREA OF THE INTAKE
                       
MAX. OBTAINED
ITEMS REMARKS
SCORE SCORE
A1. ARE ADEQUATE SIGNAGES PROVIDED IN THE EXCAVATION AREA (OBSERVATION)? 5      
A. GENERAL CONDITIONS

A2. DOES EXCAVATION UNDERMINE EXITING STRUCTURE (OBSERVATION)? 5      

A3. ARE TREES, BOULDERS OR OTHERS HAZARDS IN THE CONTROLLED AREA (OBSERVATION)? 5      

A4. ARE SPOIL PILES LOCATED AT PROPER DISTANCE FROM THE EXCAVATION AREA (OBSERVATION)? 5      

A5. ARE LADDERS, RAMP, ETC. PROVIDED FOR ESCAPE (OBSERVATION)? 5      

A6. . IS THEIR AVAILABLE OF AUTHORIZED REPRESENTATIVE (ENGINEER/SUPERVISOR) AT THE SITE (BY

CHECKING ATTENDANCE REGISTER/ RECORD)?
5      

B1. ARE THE INTAKE AREA & ROADS WATERED TO MINIMIZE DUST GENEARATED (OBSERVATION)? 5      

B2. IS THE SITE KEPT CLEAN AND TIDY E.G. LITTER FREE, GOOD HOUSEKEEPING (OBSERVATION)? 5      
B. ENVIRONMENTAL ASPECTS

B3. ARE SUFFICIENT TEMPORARY TOILETS (MALE & FEMALE; SEPARATE URINE AND DEFECATION
FACILITIES FOR MALE & FEMALE) ESTABLISHED AT LABOR CAMP IN PROPER POSITION (OBSERVATION)?
3+1+1      

B4. ARE STOCKPILES OF DUSTY MATERIALS (E.G. SIZE WITH MORE THAN 20 BAGS CEMENT) COVERED OR
WATERED? ARE CEMENTS DEBAGGING PROCESS UNDERTAKEN IN SHELTERED AREAS (OBSERVATION)?
2+3      

B5. IS SURFACE WATER OR RUNOFF DIVERTED OR CONTROLLED TO PREVENT ACCUMULATION IN THE

EXCAVATION (OBSERVATION)?
5      

B6. ARE SEPARATELY LABELED CONTAINERS/AREAS PROVIDED TO COLLECT, SEGREGATE, DISPOSE AND
RECYCLE WASTE (OBSERVATION)?
1+2+1+1      

B7. DO NOISE AND VIBRATIONS PRODUCED FROM THE CONSTRUCTION VEHICLES, MACHINES, EQUIPMENT
COMPLY WITH THE COUNTRY’S NOISE STANDARDS (BY VIEWING DOCUMENTS, THE NOISE LEVEL
1+2+2      
PRODUCED BY EACH COMPONENTS)?
C1. ARE FIRE EXTINGUISHERS FACILITIES PROPERLY MAINTAINED AND NOT EXPIRED (OBSERVATION)? 5      
EMERGENCY

C2. IS SAFE ACCESS TO WORK PLACE (OBSERVATION)? 5      

C. OHS &

C3. STAFF TRAINING ABOUT SAFETY PROCEDURES (1) AND STDS AND HIV/ALDS, HUMAN TRAFFICKING,
COMMUNITY HEALTH & SAFETY, CONTROL OF EPIDEMIC DISEASE (2) (BY INTERVIEWING LABORS OR BY
VISUAL OBSERVATION OR/AND BY DOCUMENTS)? (PERSONNEL PROTECTIVE EQUIPMENTS (PPES) HARD
1+2+2      
BOOTS, HELMETS, GLOVES, GLASSES AND PROTECTIVE MASKS, AND MONITORING THEIR PROPER AND
SUSTAINED USAGE (2))

TOTAL SCORE (SCORE % = X/Y= …………………………..) Y= 80 X=

PREAPRED BY: DATE: APPROVED BY: DATE:

CHECKED BY: DATE