Mellitah Oil and Gas B.V.

Toolbox Talk Report Form

Plant/Site: A-100 JSA No: Date:

Work Location: Lead Trade/Discipline: PTW No:

Foreman, pipefitter, helpers, operator

Power Station Type:

Commitment, Positive Attitude, Teamwork, Communication/Participation:

A. Brief Description of Work:

1.

2.

3.

B. Checklist/Prompt for discussion (Tick where applicable)

 Type of activity to be executed established  Crane / Lifting requirements
 Know methods / Procedures to be adopted  Supporting Permits / Certificates
 PTW/ARA Precautions, mitigation & controls  Hazards / Hazardous substances
 Safety equipment & location  MSDS reviewed (if required)
 Individual roles / Responsibilities  Isolation Requirements
 Access / Egress  Conflicting Activities
 Gas test / Monitoring  Work in Adjacent Areas
 Proper Work Equipments / Tools  Environmental Considerations
 Personal Protective Equipments  Waste Management
 Site Rules

Toolbox Talk Presenter Checklist Yes No

 Are all members of the work party aware of the hazards involved with the work activity?
 Are all members of the work party aware of the control measures required to mitigate?
 The person in-charge understands the requirement to provide a “Toolbox Talk” to any
new people joining the work party?
 Does everyone know what to do in the event of a site alarm or emergency?

Note: If the answer to any of these questions is NO, then the safety of the people is at risk and must be
addressed.
MOG-HSEQ-F-120 Rev A7 Page 1 of 2

Mellitah Oil and Gas B.V.

Toolbox Talk Report Form

C. Special Precautions / General Comments / Observations Identified During Toolbox Talk:

Action Required? Yes No

D. Toolbox Talk Attendees:

Name Tally No. Signature Name Tally No. Signature

E. Toolbox Talk Conducted by:

Name: Signature: Date:

MOG-HSEQ-F-120 Rev A7 Page 2 of 2