ANNEXURE-1

Name of contractors :
Contract No. :
Month of the Month
Business Unit
A) Total Man-hours Worked During The Month

Sl. No. Description Number Man-hours worked Total

1 Company Staff 21
2 Sub- contractor 38
Total 59

B) Safe man-hours from last reportable Lost time injury: 0 Hr

C) Details of Reportable Lost Time Injury

Man-days lost
Sl. Name of Date of Resumed Up to last This Total Claim
No Injured Accident duty on month month (1+2) Status
(1) (2)
1 NA NA NA NA NA NA NA

D) Number of Dangerous Occurrences : ______ 00___________

E) No of Near Miss Cases : ______ 00___________
F) No. of Unsafe Act / Condition : ______ 00__________
G) Number of first aid cases : _______00__________
H) Number of TBT conducted : _______14__________
I) Average Number of person/workers Daily: _______56__________
J) Noise monitoring record: ___________________
K) Illumination record: ___________________

Routed through
Chief Project Manager Chief Safety Manager

Signature:____________ Signature:_____________
Date: Date: