Annex 04

REGISTRATION OF WORKERS AND PPE DISTRIBUTION

 REGISTRATION OF WORKERS

Employer: Ministry of Energy and Water – National Directorate of Water Supply and Sanitation
Work: DESIGN AND CONSTRUCTION OF NETWORK AND HOUSE CONNECTIONS IN THE CITY OF MALANJE
Contractor: Jiangsu Geology & Engineering Co., Ltd

Name of B.I. or Passport Employment Professional Work accident Medical fitness Training (Yes or Distrib. of PPES (Yes or
N.º Employer body Pay slip
employee N.º contract Category insurance form No) No)

Page. 1/3
 PPE DISTRIBUTION REGISTRATION AND INFORMATION ON RISKS

Employer: Ministry of Energy and Water – National Directorate of Water Supply and Sanitation

Work: DESIGN AND CONSTRUCTION OF NETWORK AND HOUSE CONNECTIONS IN THE CITY OF MALANJE

Contractor: Jiangsu Geology & Engineering Co., Ltd

Worker Name Category N.º

Employer:  Trab. independent  Contractor  Sub -Contractor(Name: ___________________________________________________)

Ref.ª Designation of PPE Risks to Protect (1) Reception (2) End return (3)
Date: _____/____/____ Date: _____/____/____
Ass.: _______________ Ass.: _______________

Date: _____/____/____ Date: _____/____/____

Ass.: _______________ Ass.: _______________

Date: _____/____/____ Date: _____/____/____

Ass.: _______________ Ass.: _______________

Date: _____/____/____ Date: _____/____/____

Ass.: _______________ Ass.: _______________

(1)
Display codes according to the table below (2)
Date and signature of employee (3)
Date and signature of the recipient

RISKS TO PROTECT
1 – Fall from height 11 – Headbeats
2 – Fall to the same level 12 – Cuts
3 – Falling objects 13 – Shrapnel
4 – Fall by slipping 14 – Pinches
5 – Sharp or pointed objects 15 – Electrocution
6 – Crushing foot 16 –
7 – Twist foot 17 –
8 – Malleolum shock 18 –
9 – Shock at the level of the metatarsal 19 –
10 – Shock at the level of the leg 20 –

STATEMENT
I declare that I have received the above mentioned Personal Protective Equipment (PPE) and that I have been informed
of the respective risks that they intend to protect, and undertake to use them correctly in accordance with the
instructions received, to keep them and to keep them in good condition. , and to report to my superior any damage or
deficiency known to him.
I further declare that I have been informed that I am covered by occupational accident insurance under the policy. No.
____________________ of the insurance company_______________________________ ___________.

Worker Signature: ___________________________________________________________ Data: _____/____/____

Responsible Contractor of the OHS Technical Director of Contract / Work

Date: ____/____/____ Date: ____/____/____

Signature: ____________________________ Signature: ____________________________

Page. 1/3