First Day Site Induction Course/ First Day Safe-Workforce Course Form

Appendix 04
Section 1: General Information REV01
Project Name: Project / Factory Number:
Full Name (as in NRIC, WP, ID): NRIC/WP/ID No: Nationality:

Subcontractor / Employer: Appointment on project: Induction Date:

Trade: Medical Condition (if any):

Competency Certificates relevant to appointment on project, please mark with ‘X’ (copies of certificates must be attached)
CSOC (min. required) CSCPM BCSS WSH Coordinator / WSQ WSH Officer / WSQ Level C
Level B
Other SOC___________ Risk Formwork Explosive Powered Tool Occupational First Aid
Management Supervision Operator

Lifting Supervision Rigging Signalling Confined Space Safety WAH for Supervisor
Assessor

Scaffold Supervision Scaffold Erection WAH Foundation Crane Operator (Tower / Crawler / Mobile / Lorry Crane*)

SIC Manhole for Sup Welder’s Exempted Equipment Operator (Excavator / Piling / Forklift / MEWP*)
qualification

COVID-Safe Training1 Safe Management Officers / SDO Swab Test Results1 Others, pls specify
for Workers Course for Construction2 Can Work on Site?1
Note: 1 – Compulsory to submit for all S-Pass & Work Pass, failure to submit will not allowed to attend the course. 2 – for SMO & SDO appointment
Section 2a: Site Lifesaving Rules

Never enter a confined space unless trained, authorized Never operate plant, equipment or tools unless trained,
1. 7.
and an entry permit has been completed. authorized and verified as competent.

2. Never work at heights without fall protection. 8. Never access or modify scaffolding unless authorized.

Never access an excavation deeper than 1.2m that has not

Never disable, bypass, modify or remove any safety
3. 9. been sloped, benched or shored and an excavation permit
protection devices without authorization.
completed.
Never commence work until all energy sources have been
10 Never drive, or work under the influence of drugs or alcohol.
4. identified & isolated (LOTO) in accordance with project
. (Alcohol and/or drug consumption is strictly prohibited).
procedures.
Never use a communication device while operating vehicles
Never allow yourself or others to be under a suspended 11
5. and mobile equipment. Always pull over, make the vehicle
load or within a load shadow. .
safe before using the device.

12 Never direct or instruct any other person to violate or

6. Never disregard or bypass signage or barricading.
. breach a lifesaving rule.

Section 2b: ESH & COVID Safe & Healthy Worksite Key Instructions to Note
Safety COVID Safe & Healthy Worksite
1. Wear the mandatory PPE when on site. (Helmet / Safety Glass / Safety Hand Safe Entry
Gloves / Reflective Vest / Mid-cut or High-cut Safety Shoes / Long sleeves shirt) 13. If anyone feeling unwell or showing symptoms must inform employer, consult
2. Report any hazard, unsafe act, condition or chemical spill to your Supervisor / doctor immediately & self-quarantined at site designated isolation room while
Hexacon waiting for ambulance (if)
3. Report any incident or injury to your Supervisor / Hexacon immediately 14. Not feeling well, must go for ART test with negative result before report
4. Always obey and follow the safe work procedures / instructions given to you by your 15. All must maintain good personal hygiene.
Supervisor / Hexacon 16. All must wash hands & use hand sanitizer frequently.
5. Always speak up and ask questions when you have doubts or concerns. You have Safe Workforce
the right to Stop Work if you feel it is unsafe.
17. Try to maintain social distancing minimum 1m away from each other at all time.
6. Attendance at daily Pre-Start Briefings and Weekly Mass Toolbox meetings are
compulsory when working on site. 18. Must use designated walkway at individual work zone.
7. Always check and ensure a Permit To Work is applied and approved by Hexacon 19. Do not engage unnecessary interactions with others.
for your work where required. 20. Comply with staggered meal timing given to you.
8. Know your emergency escape route(s). Do not obstruct passageways, exit routes 21. Loading/Unloading to be done at designated point & zone.
and emergency equipment.
Environmental
9. Always maintain good housekeeping of your work area and dispose wastes in
designated bins provided.
10. Clear stagnant water & apply chemicals to prevent mosquito breeding.
Health
11. Ensure you are adequately rested and fit when you report to work. Inform your
Supervisor / Hexacon if you feel unwell at any time.
12. Mask to wear at indoor areas

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Section 3: Declaration by Inductee

I declare that I have been issued the following PPE by my company / employer to work on this site. I agree to use, care for and maintain this PPE to
the best of my ability. I understand that I am responsible to request for replacement of PPE if they are no longer usable or in serviceable condition. I will
also ask for the required PPE for the job I have been tasked.
Safety Helmet Eye Goggles Safety Boots Safety Vest Hand Glove
Mandatory PPE:

Task Specific Ear Plug Respiratory Mask

Safety Harness Mask
PPE:

Others:- Hand Sanitizer & Arm Band (colour please indicate: ________________)

Section 4: Verification & Endorsement

I have undergone the SIC and understood the information presented / translated to me. I agree to abide by the rules and regulations governing the project
and will exercise due diligence to work in a safe and orderly manner so as to ensure the safety and well-being of myself and my fellow workmates, and the
protection of the environment

Name of Inductee (print name): ............................................. Signed: ................................ Date: ….../…..../…... Time: .............am / pm

Witnessed By:
Supervisor (print name): ………………………………. Signed: ……………………... Date: ……/…../……. Time: …………am / pm

Verification & acknowledgement by Hexacon

Security Pass issued: Yes / No / Temp* Security Pass No: ................................................

Hexacon (print name): ....................................................... Signed: ............................... Date: ......./…..../….... Time: .............. am / pm

Section 5: Health Declaration

Have you ever had or been told to have or been treated for:

Epilepsy / fits, stroke, paralysis / weakness of limb, prolonged headache, nervous breakdown, Yes No
01
depression or any other nervous / mental disorders?

Ear discharge, nose bleeds, double vision, impaired sight, hearing, or speech or any other disorders of Yes No
02
ear, eye, nose and throat?

Asthma, bronchitis, persistent cough, coughing with blood, pneumonia, tuberculosis, breathing Yes No
03
complaints / discomfort or any other lung disorders?
Raised cholesterol, high blood pressure, heart attack, mitral valve prolapses or other heart valve Yes No
04 disorders, breathlessness, fast heart rate, chest pain, or any disease or disorders of the heart or blood
vessels?

05 Diabetes mellitus, thyroid disorders or any endocrine disorders? Yes No

Gastritis, stomach or duodenal ulcer, blood in stools, fistula, piles or any other stomach or bowel Yes No
06
disorder?

07 Jaundice, hepatitis B carrier or any form of hepatitis, liver or gallbladder disorder? Yes No

08 Blood, protein or sugar in urine, kidney stones, infection or any other disorders of the kidney Yes No

09 Cancer, tumour, cyst or growth of any kind? Yes No

Slipped disc, backache, gout, arthritis, pain or deformity or disorders of the muscles, spine, limbs or Yes No
10
joints or severe injury?
Any other illnesses, disorder, operation, physical disability, accident, hospitalization, congenital or Yes No
11
hereditary disorders not listed above?

12 Are you currently under any form of medication prescribed by the doctor? Yes No

13 Have you travelled to and from any country within the last 14 days? Yes No

14 Are you currently serving Quarantine Order (QO), Leave of Absence (LOA) or Stay-Home Notice (SHN)? Yes No

Within the last 14 days, have you had contact with a COVID-19 (Coronavirus Disease 2019) confirmed Yes
15 case or suspect case, or a person issued Quarantine Order (QO) / Leave of Absence (LOA) / Stay-Home No
Notice (SHN)?

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 Are you feeling unwell or having any respiratory symptoms (such as fever, cough, sore throat or runny
16 Yes No
nose)?

17 Have you completed SWAB/COVID-19 test? Yes No

Section 6: Completed by SIC Trainer

01 Blood Pressure Level (To be taken by SIC trainer)

02 Temperature (To be taken by SIC trainer)

I hereby declare that all the information on form is true and complete to the best of my knowledge and consent to release my health information
to be shared within Hexacon Construction Pte Ltd.

Inductee (name): ……………………………………Signed: ............................Date: ….../…..../…… Time: .............. am / pm

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