Safety Inspection Forms

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SECTION: D
SAFETY INSPECTION FORMS
HEALTH, SAFETY & ENVIRONMENT

DEPARTMENT
ISSUE, REV. 8
2020
Saudi Binladin Group
Form List
Document No: SBG-HSE-000 Revision: 8
Date Modified:
Title Reference Rev. Pages

MONTHLY / WEEKLY SAFETY REPORT SBG- HSE -001 8 2
DAILY SAFETY INSPECTION CHECKLISTS SBG- HSE -002 8 4
INJURY SUMMARY SBG- HSE -003 8 1
PRELIMINARY ACCIDENT REPORT SBG- HSE -004 8 1
FATAL ACCIDENT REPORT SBG- HSE -005 8 1
INTERNAL INCIDENT REPORT SBG- HSE -006 8 1
FINAL ACCIDENT REPORT SBG- HSE -007 8 3
NON CONFORMATION REPORT (NCR) SBG- HSE -008 8 1
DAILY REPORT SBG- HSE -009 8 1
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FIRE FIGHTING EQUIPMENT,EMERGENCY LIGHTING INSPECTION LOG SBG- HSE -010 8 3

TOOL BOX MEETING MIMUTES SBG- HSE -011 8 1
FIRE EXTINGUISHER LOCATION CHECKLIST SBG- HSE -012 8 2
NEAR MISS REPORT FORM SBG- HSE -013 8 1
CRANE & LIFTING EQUIPMENT SBG- HSE -014 8 4
TRANSPORT AND HEAVY EQUIPMENT SBG- HSE -015 8 23
GAS CUTTING APPARATUS SBG- HSE -016 8 2
ELECTRICAL OPERATED HAND POWER TOOLS SBG- HSE -017 8 1
CRANE SET-UP CHECK LIST SBG- HSE -018 8 1
EMERGENCY CONTACTS LIST SBG- HSE -019 8 1
HAND, POWER, PNEUMATIC & CARTRIDGE OPERATED TOOLS SAFETY CHECKLIST SBG- HSE -020 8 3
LADDER SAFETY CHECKLIST SBG- HSE -021 8 1
EXCAVATION DAILY INSPECTION SHEET SBG- HSE -022 8 1
FORKLIFT CHECKLIST SBG- HSE -023 8 2
WELFARE CHECKLIST SBG- HSE -024 8 2
FABRICATED FRAME SCAFFOLDS INSPECTION CHECKLIST SBG- HSE -025 8 1
ORAL SCAFFOLDING INSPECTION CHECKLIST SBG- HSE -026 8 6
MOBILE SCAFFOLDS INSPECTION CHECKLIST SBG- HSE -027 8 1
TUBE AND COUPLER SCAFFOLDS INSPECTION CHECKLIST SBG- HSE -028 8 2
LIFT PLAN FOR CRANES SBG- HSE -029 8 1
EQUIPMENT CHECKLIST SBG- HSE -030 8 1
WASTE LOG CHECKLIST SBG- HSE -031 8 1
CONFINED SPACE ENTRY PERMIT SBG- HSE -032 8 2
EXCAVATION WORK PERMIT SBG- HSE -033 8 2
HOT & COLD WORK PERMIT CHECKLIST SBG- HSE -034 8 3
WORKING HEIGHT / WORK PERMIT SBG- HSE -035 8 2
ELECTRICAL PERMIT TO WORK SBG- HSE -036 8 2
PERMIT TO WORK EXTENDED HOURS & NIGHT WORK SBG- HSE -037 8 2
RADIOGRAPHY PERMIT SBG- HSE -038 8 2
LIFTING / RIGGING OPERATION PERMIT SBG- HSE -039 8 5
GENERATOR INSPECTION REPORT SBG- HSE -040 8 3
SAFETY CHECKLIST FOR WELDING & CUTTING TOOLS SBG- HSE -041 8 1
CRITICAL LIFTING PLAN FOR FORM SBG- HSE -042 8 2
SCAFFOLD CHECKLIST SBG- HSE -043 8 2
SCAFFOLD ERECTION REQUEST SBG- HSE -044 8 1
OFFICE SAFETY INSPECTION SBG- HSE -045 8 1
DAILY ENVIRONMENTAL INSPECTION REPORT SBG- HSE -046 8 10
VISITOR ORIENTATION CHECKLIST SBG- HSE -047 8 1
ELECTRICAL PANELS INSPECTION SBG- HSE -048 8 5
WALK THROUGH SBG- HSE -049 8 1
SAFETY CHECKLISTS FOR SAFET HARNESS SBG- HSE -050 8 1
FIELD TOURS SBG- HSE -051 8 1
HAND TOOL CHECKLIST SBG- HSE -052 8 2
MONTHLY AUDIT FOR DELIVERABLES SBG- HSE -053 8 53
Copyright Saudi Binladin Group Page 1
Copyright Saudi Binladin Group
Printed copy is uncontrolled and only valid at the time of printing. Always refer to the electronic copy as the latest version.
‫‪Saudi Binladin Group‬‬
‫إرشادات عامة‬
‫‪Document No: SBG-HSE-G‬‬ ‫‪Revision: 8‬‬
‫‪Date Modified:‬‬
‫مرفق نماذج الفحص و التفتيش الخاص ببرنامج السالمة ‪:‬‬
‫ونود التنويه علي ما يلي ‪:‬‬

‫‪Download HSE Docs hseprof.com‬‬
‫‪SBG-HSE-CONSTRUCTION SAFETY INSPECTION CHECKLISTS‬‬ ‫‪ -1‬النموذج‬
‫هو نموذج أساسي يجب تعبئته يوميا وهو يمثل الحد األدنى من متطلبات السالمة الواجب‬
‫توافرها باألنشطة المختلفة بالمشروع ‪.‬‬
‫‪ -2‬قوائم الفحص من ‪ 1‬الى ‪ 13‬هى قوائم أساسية تمثل الحد األدنى من متطلبات السالمة ‪.‬‬
‫‪ -3‬قوائم الفحص من رقم (‪ ) 53-14‬نماذج متخصصة تستخدم وفقا للحاجة وكذلك وفقا لخبرة‬
‫وتقدير وتقييم مسئول السالمة بالمشروع للوضع على الطبيعة ‪.‬‬
‫‪Copyright Saudi Binladin Group‬‬

‫‪Printed copy is uncontrolled and only valid at the time of printing. Always refer to the electronic copy as the latest version.‬‬
MONTHLY / WEEKLY SAFETY REPORT

Document No: SBG-HSE - 001 Revision: 8
Date Modified:
MONTHLY SAFETY REPORT ‫تقرير احصائيات السالمة الشهري‬

Project Title Location
‫المشروع‬ ‫الموقع‬
Duration Contractor
......./...../........... ‫إلي‬...... /...../......... ‫من‬
‫المدة الزمنية‬ ‫المقاول‬
Contract No. : ‫رقم العقد‬
Current Month
1. PROJECT INFORMATION ‫معلومات عن المشروع‬ This Month No.
Cumulative No.
‫رقم هذا الشهر‬
‫الرقم التراكمي للشهر‬
1.1 Total Man-hours Worked ‫إجمالى عدد ساعات العمل المؤدى‬
1.2 No of Employees (Last Day) (‫عدد الموظفين (من اخر يوم عمل‬
1.3 No of Safety Eng. /Officers at Site ‫مسئولى السالمة بالموقع‬/ ‫عدد مهندسي‬
1.4 No of Equipment at Site ‫عدد المعدات بالموقع‬
2. HEALTH SAFETY ‫الصحة و السالمة‬
2.1 Fatalities (FAT) ‫الوفيات‬
2.2 Lost Time Accident (LTA) ‫الوقت المهدر نتيجة الحوادث‬
2.3 Near Misses (NM) ‫الحوادث الوشيكه‬
2.4 Major Accident ‫اإلصابات الشديدة‬
2.5 Occupational Illness Cases ‫حاالت األمراض المهنية‬
2.6 Total Recordable Incidents (TRI) ‫إجمالى الحوادث المسجلة‬
2.7 First Aid Cases (FAC) ‫حاالت االسعافات االولية‬
2.8 Safety Violation Raised ‫معدل مخالفات السالمة‬
2.9 Fire Accident ‫حوادث حريق‬
2.10 Asset Damages (AD ( ‫إلخ‬.... - ‫التلفيات (للمعدات – المبانى‬
2.11 Road Traffic Accidents (RTA) ‫حوادث المرور‬
2.12 Termination ‫فصل من العمل‬
3. TRAINING AWARENESS ‫التدريب والتوعية‬
3.1 Tool Box in Health & Safety Topics ‫المحاضرات العملية الخاصة بالسالمة‬
3.2 Safety induction ‫تعريف السالمة‬
3.3 Task Safety Analysis (TSA) Briefings ‫موجز تحليل السالمة‬
3.4 Safety Representatives Meetings ‫إجتماعات مندوبى السالمة‬
3.5 Internal Training in IMS Procedures ‫تدريبات داخلية موجز اسلوب العمل‬
3.6 External Training Courses ‫دورات تدريبية خارجية‬
4. MONITOR & AUDIT ‫مراقبة و تدقيق‬
4.1 No of Internal Audits ‫تقارير المراجعة الداخلية‬
4.2 No of site HSE Inspections ‫عدد مرات التفتيش على السالمة و الصحة و البيئة‬
4.3 Project Management Safety Tours ‫جوالت السالمة من قبل إدارة المشروع‬

5. CONSULTANT AUDIT
5.1 No of Internal Audits ‫تقارير المراجعة الداخلية‬
5.2 No of site HSE Inspections ‫عدد مرات التفتيش على السالمة و الصحة و البيئة‬
5.3 Safety Consultant Tours ‫جوالت السالمة من قبل استشاري السالمة‬
5.4 Safety Consultant Observation (Close / Open) ‫مالحظات استشاري السالمة‬
5.5 K P I Rates ‫مقياس معدل االداء‬
6. SPI Results ‫نتائج تقييم مستوى السالمة‬

TOPICS DISCUSSED at Tool Box Meeting ‫الموضوعات المطروحة للنقاش‬
ATTENDANCE ‫كشف الحضور‬
7. ATTACHMENTS -None- ‫المرفقات‬
Instructor(s): ‫المشرف العام‬
PREPARED BY: ‫إعداد‬ REVIEWED BY: ‫مراجعة‬
SIGNED BY ‫الذي وقعها‬ Date ‫التاريخ‬

DAILY SAFETY INSPECTION CHECKLIST

Date Modified:
DAILY SAFETY INSPECTION CHECKLIST
‫قائمة فحص السالمة اليومية‬
Project No.: ‫رقم‬ Project Name:
:‫المشروع‬ ‫اسم المشروع‬
Date Inspection
Conducted: Location: ‫الموقع‬
‫تاريخ الفحص‬
Name of the Safety Manager / Officer:
‫مسئول السالمة‬
Name(s) of person(s) participating in this

inspection : ‫القائم بالفحص‬
PERSONAL PROTECTIVE EQUIPMENT ( ‫) معدات الوقاية الشخصية‬ REMARKS

Safety glasses and / or goggles available & being ‫هل نظارات السالمة متوفرة ومستخدمة؟‬
used?
Face shield available for bulk liquid tasks? Grinding?‫واقي الوجه متوفر‬
Hand protection used/worn as required? ‫واقي اليد متوفر ومستخدم؟‬
Foot protection worn as required? ‫واقي األرجل متوفر؟‬
Hearing protection worn where required? ‫واقي القوى السمعية متوفر عند الحاجة‬
Hard hats worn on work site? ‫الخوذة متوفرة‬
Respirators if required? Type? ‫اجهزة التنفس وتنقية الهواء متوفرة عند الحاجة‬
Fall protection, full body harness & ‫مهمات الوقاية من السقوط (احزمة السالمة) متوفرة؟‬
lanyard used > 1.8m?
ELECTRICAL SAFETY ( ‫) السالمة الكهربائية‬ REMARKS
ELCB’s used for all portable ‫مانع التسريب االرضي مستخدم لجميع المعدات اليدوية الكهربية؟‬
electrical hand tools?
Electrical panels are labeled ‫اللوحات الكهربية تم ترميزها ووضع العالمات عليها؟‬
appropriately
ELCB’s are inspected periodically? ‫يتم فحص مانع التسريب االرضي دوريا‬
LO/TO is being used for appropriate tasks ‫نظام الغلق والوسم مستخدم للعمليات الالزمة‬
Strain relief integrity for cords and plugs intact ‫الوصالت واالفياش مقاومة للشد؟‬
For extension cords: hard usage cord includes three-wire ‫استخدام التوصيالت الثالثية‬
cords marked
Electrical cords inspected & have all prongs intact ‫جميع االفياش مفحوصة وامنة‬
Portable generators are grounded per requirements? ‫تأريض جميع المولدات الكهربائية‬
Electrical power tools are double insulated or ‫العزل الثنائي لجميع االجهزة الكهربائية‬
grounded
COMPRESSED GASSES ( ‫) الغازات المضغوطة‬ REMARKS
Compressed gas cylinders stored secured & ‫اسطوانات الغاز المضغوط مخزنة جيدا ومؤمنة‬
upright
Oxygen/acetylene torch units have ‫اسطوانات األوكسجين واألسيتيلين بها مانع ارتداد اللهب‬
flash back arrestors
Fire precautions in place for storage & ‫احتياطات الوقاية من الحريق للتخزين واالستخدام‬
during use?
HAZ COM ( ‫) التواصل بشأن المواد الخطرة‬ REMARKS
SDS openly available to all employees? ‫صحيفة بيانات المواد الكيمائية متاحة لكل الموظفين‬
Flammable liquids are in approved safety ‫السوائل القابلة لالشتعال في حاويات مناسبة وامنة؟‬
cans?
Flammable liquids storage containers ‫يتم وضع الملصقات على حاويات السوائل القابلة لالشتعال‬
labeled properly?
All hazardous containers ‫وضع الملصقات على جميع الحاويات التي تحتوي على المواد الخطرة‬
labeled appropriately?
Supplies on hand for accidental ‫توفر االمكانيات الالزمة للتعامل مع االنسكابات الكيميائية‬
chemical spills?
LADDER/STAIR SAFETY ( ‫) سالمة الساللم والدرج‬ REMARKS
Ladders are safe and inspected as appropriate? ‫الساللم آمنة ومفحوصة‬
Stepladders are only used in open position?‫السلم المزدوج يستخدم فقط في الوضع المفتوح‬
Stairs or ladder provided for access points‫الساللم والدرج تستخدم لنقاط الوصول‬
Extension & straight ladders extend 3’ beyond ‫ قدم بعد سطح المنصة‬3 ‫امتداد السلم‬
landing?
CONFINED SPACE ( ‫) االماكن المغلقة‬ REMARKS
Confined space entry work? ‫هل يوجد اعمال في االماكن المغلقة؟‬
Permit for Confined spaces?‫هل يوجد تصريح عمل لالماكن المغلقة‬
Confined Space attendant standby?‫توفر مراقب للمكان المغلق طوال فترة العمل‬
Air monitoring conducted and recorded? ‫يتم مراقبة قياسات الهواء ويتم تسجيلها‬
Adequate warning signs and barricades? ‫العالمات التحذيرية المناسبة والحواجز‬
Are adequate lighting & ventilation provided and maintained?‫االضاءة والتهوية مناسبة؟‬
MATERIAL HANDLING ( ‫) مناولة المواد‬ REMARKS

Employees operating any equipment are trained on the equipment?
‫مشغلو المعدات مدربون ؟‬
Wire rope and web slings used for lifting ‫حالة الويرات وادوات التصبين بحالة جيدة؟‬
Deterioration is absent?
Outriggers are applied in safe position ‫ركائز االوناش موضوعة في وضع صحيح ومستقرة‬
and equipment stable?
Crane used? Approved written plan on file w/ ‫هل حمل التشغيل االمن موضح لكل االوناش‬
load capacities?
Hooks used for lifting have safety latch in place ‫وجود قفل السالمة الخاص بالهوك الرئيس‬
EXCAVATION ( ‫) الحفر‬ REMARKS
‫ قدم بين السلم‬50 ‫ قدم ومسافة‬3 ‫ قدم امتداد عن الحفة‬4 ‫التزود بساللم عندما يكون العمق أكبر من‬
Excavation-ladders if > 4ft deep? Extend 3 ft? 50 ft apart? ‫واالخر‬
Excavation – Adequate protection from ‫الحماية الجيدة من التكهفات أماكن تسمح بالتهييل ؟‬
cave-ins?
Sloping, shoring evaluated and is safe? ‫عمل االنحدارات والتدعيم‬

Daily inspection? ‫الفحص اليومي‬
HAND TOOLS/POWER TOOLS ( ‫) االدوات اليدوية‬ REMARKS

Grinders (portable & stationary have guards in place‫معدات التجليخ بها حواجز الحماية‬
Impact style air tools have safety ‫المعدات التي تعمل بالهواء المضغوط بها كلبسات االمان‬
clips/retainers installed?
Pneumatic power tools have hoses secured ‫تامين الخراطيم الخاصة بالهواء‬
Portable circular saws equipped with ‫المنشارالكهربي المحمول به حواجز الحماية المناسبة‬
protective guards
Unsafe hand tools are prohibited ‫منع استخدام االدوات غير اآلمنة‬
Impact tools, hammers kept free of splinters / mushrooms ‫حالة االدوات امنة‬
GENERAL SAFETY ( ‫) السالمة العامة‬ REMARKS

General housekeeping is neat and orderly ‫حالة النظافة العامة جيدة؟‬
Wall openings & floor holes are covered or ‫فتحات الحوائط واالرضيات مغطاة ومؤمنة‬
guarded
Rebar caps used for protruding bars? ‫اغطية اسياخ الحديد مستخدمة‬
Safety training conducted regularly and ‫تدريب السالمة يتم عمله بشكل دوري وحفظ الوثائق؟‬
documented?
Scaffolding–guardrails used ‫نظام الدرابزين مستخدم في السقاالت‬
Competent person on site? ‫االشخاص المختصين في مواقع العمل‬
Scaffold design by qualified person? ‫يتم تصميم السقاالت بواسطة شخص مؤهل‬
Are the scaffolds erected at site Safe to Use? ‫هل السقاالت في الموقع امنة لالستخدام‬
EMERGENCY/FIRST AID ( ‫االسعاف االولي‬/ ‫) الطوارئ‬ REMARKS
Emergency phone numbers posted and known by ‫ارقام الطوارئ منتشرة ومعروفة للكل؟‬
all?
Emergency eyewash and/or shower units ‫مغاسل االعين واماكن االستحمام متوفرة؟‬
accessible?
First aid kit available at work site? ‫حقائب االسعافات االولية متوفرة‬

Fire extinguishers readily available not blocked‫طفايات الحريق متوفرة وسهل الوصول اليها‬
Fire extinguishers inspected ? ‫طفايات الحريق مفحوصة‬
Hot work permits used for grinding, cutting welding? ‫استخدام تصاريح لألعمال الساخنة؟‬
Exits marked? Not blocked? ‫وجود عالمات الخروج واضحة وعدم انسداد المخارج‬
Emergency Plan available and known by all? ‫وجود خطة طوارئ ومعروفة من كل العمال؟‬
Responsibilities assigned for emergencies? ‫وجود مسئوليات واضحة لألشخاص اثناء الطوارئ‬
OTHER REMARKS
Permits in place Hot work, Excavation, Confined space, etc? ‫تطبيق نظام تصاريح‬
‫العمل‬
Tool-box talks conducted and documented?‫عمل محاضرات التوعية اليومية‬

Signs/signals/barricades in place? ‫العالمات التحذيرية موجودة‬
Training conducted and documented? ‫التدريب يتم عمله وتوثيقه‬
Health and Safety Plan available and ‫خطة السالمة والصحة المهنية موجودة ومتاحة للعمال‬
reviewed with workers?
Occupational Health & Safety Policy ‫سياسة الصحة والسالمة موجودة ومعروضة للكل؟‬
displayed?
REMARKS AND OBSERVATION ‫المالحظات‬
)‫(إعداد‬Prepared by: )‫ (مراجعة‬Reviewed by:

INJURY SUMMARY
Date Modified:
Injury Summary for the Month of ‫ ملخص اإلصابات خالل شهر‬: _________________
Project Location: BI Number:
Contractor Name: Saudi Binladin Group ‫اسم المشروع‬ ‫رقم العقد‬
Case Date of Name of Nature of Injury, Body

Badge No. Craft Days Lost Remarks
No. Injury Injured Parts affected
‫تاريخ‬ ‫طبيعة اإلصابة و العضو‬

‫رقم الحالة‬ ‫اسم المصاب‬ ‫الرقم الوظيفي‬ ‫المهنة‬ ‫فترة الغياب‬ ‫مالحظات‬
‫االصابة‬ ‫المصاب‬
Report Prepared by: Signature:

‫إعداد‬ ‫التوقيع‬
Title: Safety Supervisor: Tel. No.

‫مشرف السالمة‬ ‫رقم الهاتف‬

PRELIMINARY ACCIDENT REPORT

Date Modified:
PRELIMINARY ACCIDENT REPORT ‫تقرير أولي للحادث‬

DETAILED REPORT TO BE SUBMITTED WITHIN 3 DAYS
‫يكتب تقرير الحادث الداخلى ويسلم فى خالل مدة ال تزيد عن ثالثة أيام‬
ACCIDENT – PERSON(S),MOTOR VEHICLE,EQUIPMENT OR PROPERTY
( ‫ ممتلكات‬/ ‫ معدة‬/ ‫ مركبة‬/ ‫ اشخاص‬/ ‫حادث )شخص‬
Motor Vehicle Accident: ‫حادث‬ Personal Injury: Environmental Near Miss

‫مركبة‬ ‫اصابة اشخاص‬ ‫حادث بيئي‬ ‫حادث وشيك‬
Time: Location:
Date: ‫التاريخ‬
‫التوقيت‬ ‫الموقع‬
Describe Accident: ‫وصف الحادث‬
Immediate Corrective Action(s) Taken to Prevent Recurrence: ‫اإلجراء التصحيحى الفورى الذى تم إتخاذه لمنع تكرار الحادث‬
Company: ‫الشركة‬ Injured Name(s) and Badge#(s): ‫إسم المصاب ورقم هويته‬
Injury or Illness: ‫اإلصابة او المرض‬: Witness Statement(s): ‫اقوال الشهود‬
MOTOR VEHICLE (ADDITIONAL INFORMATION) ‫معلومات إضافية لحوادث المركبات‬

Name of Driver: ‫اسم السائق‬ Badge: ‫رقم الهوية‬ Vehicle # or Plate # ‫رقم اللوحة‬ CM
‫المدير اإلنشائي‬
Other ‫اخرون‬
Accident Involved the following SA Vehicle Contractor Vehicle Fixed Object
‫تضمن الحادث االتي‬ ‫مركبة سعودية‬ ‫مركبة المقاول‬
‫جسم ثابت‬
Sub-Contractor
Private Vehicle
Other: ‫____________________اخرون‬ Vehicle
‫مركبة خاصة‬
‫مركبة مقاول الباطن‬
No. of People in 1st Vehicle? Of those injured how many
‫عدد االشخاص في المركبة‬ How many Injured?
were wearing seat belts?
1 ‫رقم‬ ‫عدد المصابين‬
‫عدد من كان يرتدى حزام االمان‬
No. of People in 2nd Of those injured how many
How many Injured?
Vehicle? were wearing seat belts?
‫عدد المصابين‬
2 ‫عدد االشخاص في المركبة رقم‬ ‫عدد من كان يرتدى حزام االمان‬
Who Reported to the Accident Scene? Safety Section Govt. Affairs
‫من حضر إلي موقع الحادث؟‬ ‫قسم السالمة‬ ‫ممثل الحكومة‬
Nationalities: ‫الجنسيات‬
CM / Contractor Safety: Local Police Security
‫المدير اإلنشائي للمقاول‬ ‫الشرطة‬ ‫األمن‬
Prepared By: ‫إعداد‬ CM Rep.: ‫المدير اإلنشائي‬
Position: ‫الوظيفة‬ Position: ‫الوظيفة‬
Signature: ‫التوقيع‬ Signature: ‫التوقيع‬
Date: ‫التاريخ‬ Date: ‫التاريخ‬

FATAL ACCIDENT REPORT

Date Modified:
FATAL ACCIDENT REPORT ‫تقرير حادث وفاة‬

DETAILED REPORT TO BE SUBMITTED WITHIN 24 HOURS ‫ ساعة‬24 ‫يجب تقديم تقرير مفصل خالل‬
INVOLVED PARTIES ‫األطراف المشتركة في الحادث‬
Motor Vehicle: ‫مركبات‬ Personal: ‫اشخاص‬ Equipment ‫معدات‬ Property ‫ممتلكات‬

Location:
Date: ‫التاريخ‬ Time: ‫الوقت‬
‫الموقع‬
Describe Accident: ‫وصف الحادث‬
Company: ‫الشركة‬ Deceased Name(s) and Badge#(s): ‫اسم المتوفي ورقم هويتة‬
Police Case No.: ‫رقم محضر الشرطة‬ No. of Photograph: ‫عدد الصور‬
List of Persons charged by

List of Persons failed in their safety
Police: List of injured personnels ‫قائمة‬
Responsibilities:
: ‫قائمة باألشخاص المتهمون من قبل‬ ‫أسماء المصابين‬
‫قائمة باألشخاص المخالفين لمسئوليات وأنظمة السالمة‬
‫الشرطة‬
Proposed Charges to site conditions to prevent a Recurrence of Events that lead to the Accident: ‫التعديالت‬
‫المقترح إتخاذها على الموقع لمنع تكرار مايؤدي إلي وقوع الحوادث‬
Witness Statement(s): ‫اقوال الشهود‬
Prepared By:‫معد التقرير‬ CM Rep.: ‫ممثل ادارة المشروع‬
Position: Position:
Signature: Signature:
Date: Date:

INTERNAL INCIDENT REPORT

Date Modified:
Injury / Revision REPORT )‫ مراجعة حالة‬/ ‫تقرير (إصابة عمل‬

Location:‫الموقع‬ Date: ‫التاريخ‬ Type of case:‫نوع الحالة‬ Time: ‫الوقت‬
‫مراجعة الحالة‬ ‫إصابة عمل‬
Type: ‫النوع‬/ ‫تصنيف اإلصابة‬ Name of the injured person:‫إسم الشخص المصاب‬ Company: ‫الشركة‬
Place of injury:‫مكان اإلصابة في الجسم‬ Communication No:‫رقم التواصل‬ Profession: ‫المهنة‬
Iqama No.: ‫رقم الهوية‬ Badge No. : ‫الرقم الوظيفي‬ Nationality :‫الجنسية‬
Description of Injury: ‫وصف اإلصابة‬
Root Causes of Injury: ‫األسباب الرئيسية لإلصابة‬
Preventive Action: ‫اإلجراء التصحيحي‬
Action: ‫اإلجراءات المتخذة‬
Recommendation: ‫التوصيات‬
‫إسم مراقب المصاب‬ ‫إسم المهندس المسؤول عن المصاب‬

Supervisor name: Engineer name
‫القسم التابع له‬ ‫منطقة العمل‬

Name of department Zone
‫إسم معد التقرير‬ ‫مهندس السالمة‬

Prepared by Safety engineer
‫التوقيع‬ ‫التوقيع‬
Signature Signature
‫التاريخ‬ ‫التاريخ‬
Date Date

FINAL ACCIDENT REPORT

Document No: SBG-HSE – 007 Revision: 8
Date Modified:
Final Accident Report ‫التقرير النهائي للحادث‬

Project Title Date ‫التاريخ‬
‫اسم المشروع‬ Project No. ‫رقم المشروع‬
General Information: ‫معلومات عامة‬:
Injury Category (if any)
Type of Accident: ‫نوع الحادث‬
‫فئة اإلصابة‬
 Fire / Explosion  Lost Time Injury
 Fatality ‫وفاة‬
‫ انفجار‬/‫حريق‬ ‫ضياع الوقت بسبب اإلصابة‬
 Restricted Workday Case
 Injury (Serious or Minor)  Environmental Effect
‫حالة ادت الى تعطل يوم العمل‬
) ‫إصابات (خطيرة او طفيفة‬ ‫تأثر علي البيئة‬
 Occupational Illness  Medical Treatment Case

 Property Damage ‫تلف ممتلكات‬
‫مرض مهني‬ ‫حالة تطلبت تدحل طبي‬
 First Aid Case ‫حالة تم اسعافها‬
Date of Accident : ‫تاريخ الحادث‬ Place of Accident : ‫موقع الحادث‬
Time of Accident : ‫وقت الحادث‬ Number of persons injured : ‫عدد األشخاص المصابين‬
Details of Injured Person ( to be completed in cases of Fatality, Injury or Occupational Illness)
) ‫بيانات األشخاص المصابين ( تشمل حاالت الوفاه و االصابات و االمراض المهنية‬
Name ‫االسم‬ Occupation ‫المهنة‬
Age ‫ العمر‬Sex Nationality ‫الجنسية‬ Emp. No. Dept. / Section ‫الشركة‬/ ‫القسم‬
‫الجنس‬ ‫الرقم الوظيفي‬
Name / Address of Immediate Supervisor : ‫اسم وعنوان المدير المباشر‬
Description of Accident ( Give a brief description of the Accident - include sketches or photos as necessary )
) ‫وصف الحادث ( وصف مختصر للحادث يجب ارفاق رسومات و صور عن الحاجة‬
Witnesses ( required for major accidents ) (‫الشهود ) يجب وجود شهود في الحوادث الخطيرة‬
Company Mobile No.
Name ‫االسم‬ Occupation ‫المهنة‬
‫الشركة‬ ‫رقم الجوال‬

Nature of Accident ‫طبيعة الحادث‬
A) Fatality ‫وفاة‬  Death ‫موت‬
B) Injuries ‫اإلصابات‬ C) Illness ‫مرض‬ D) Fire / Explosion (Describe):
Amputation ‫بتر‬  Fracture ‫كسر في العظم‬  Asthma ‫ربو‬
‫ انفجار‬/ ‫)وصف(حريق‬
 Burn ‫حرق‬  Shock, Elect‫صدمة كهربائية‬  Convulsion ‫تشنج‬
 Chemical ‫كيميائي‬  Sprain ‫التواء المفصل‬  Dizziness ‫دوخة‬
 Electrical ‫كهربائي‬ Decompression

 Fainting ‫إغماء‬
‫إنخفاض في الضغط‬
 Flame ‫لهب‬  Dislocation ‫خلع‬  Intoxication ‫ثمل‬
 Crushing
 Abrasion ‫حكة وتاكل الجلد‬  Irritation ‫تهيج للجلد‬

‫إصابة إصطدام‬
 Strain ‫إجهاد‬  Laceration ‫تمزق‬  Nausea ‫غثيان‬
 Wound ‫جرح‬  Penetrating ‫آلة حادة‬  Poisoning ‫تسمم‬
 Drowning ‫غرق‬  Puncture ‫ثقب‬  Suffocation ‫إختناق‬
 Foreign Body
 Slab ‫طعنة سكين‬  Vomiting ‫تقيئ‬
‫جسم خارجي‬
C) Property Damage (Describe): (‫تلف ممتلكات (وصف‬ E) Environmental Effect: ‫تأثر البيئة‬
 Pollution ‫تلوث‬
Other Pollutions ‫تلوثات اخري‬

 Air ‫الهواء‬  Fresh Water ‫المياه العذبة‬
 Marine ‫البحر‬  Land ‫األرض‬
Details of Accident ‫بيانات الحادث‬
A) Indicate main part of body affected (tick box) ‫أشر على الجزء الرئيسي من الجسم الذي اصيب في الحادث‬
 Scalp  Forehead  Jaws  Eyes  Lips  Teeth
‫الفروة‬ ‫الجبهه‬ ‫الفك‬ ‫العين‬ ‫الشفة‬ ‫االسنان‬ 
Head: ‫الرأس‬ Others
Skull  Cheeks  Chin  Nose  Gums  Ears ‫اخرى‬
‫الجمجمة‬ ‫الخد‬ ‫ذقن‬ ‫االنف‬ ‫اللثة‬ ‫االذن‬
Neck: ‫الرقبة‬  Anterior Neck ‫الرقبة من االمام‬  Nape ‫الرقبة من الخلف‬
 Genitals
 Upper Back
 Chest ‫الصدر‬  Abdomen ‫البطن‬ ‫األعضاء‬
‫اعلي الظهر‬
Trunk : ‫الجسم‬ ‫التناسلية‬
 Lower Back  Others:
 Ribs ‫القفص الصدري‬  Buttocks ‫االرداف‬
‫اسفل الظهر‬ ‫اخرى‬
Immediate Action Taken ‫اإلجراء الفوري المتخذ‬
Probability of recurrence :  Low

 High ‫عالية‬  Medium ‫متوسط‬
‫إحتمالية تكرار الحادث‬ ‫قليل‬

Investigation of Cause(s): ‫التحقيق في اسباب الحادث‬
A) Immediate Cause ‫السبب المباشر‬ B) Underlying Cause ‫السبب غير المباشر‬
 External Factors (3rd party,
 Access / Egress  Lack of Physical ,mental capability
weather)
‫ المداخل‬/ ‫المخارج‬ ‫خلل في القوى العقلية‬
)‫ جهات خارجية‬/ ‫عوامل خارجية (الطقس‬
 Inadequate Equipment or  Inadequate Knowledge and / or
 Equipment Failure
Tools ‫المعدات واالدوات غير مالئمة‬ skill
‫خلل في المعدات‬
‫ضعف في المعرفة او المهارة‬
 Failure to observe / use
 Improper Handling warning / safety devices.  Lack of Supervision
‫تداول خاطى للمواد‬ ‫ أجهزة السالمة‬/ ‫ التحذير‬/ ‫خلل في الرصد‬ ‫اليوجد متابعة‬
 Inadequate PPE  Failure to follow rules and  Inadequate planning and / or

‫مهمات السالمة غير مناسبة‬ procedures organization

‫عدم اتباع برنامج و تعليمات السالمة‬ ‫خلل في التخطيط او التنظيم‬
 Failure to wear PPE  Inadequate Warning signs /  Inadequate work standards and
‫عدم ارتداء مهمات السالمة‬ Safety Devices /or/ procedures
‫الشخصية‬ ‫تحذيرعدم إستخدام لوحات‬ ‫خلل في مواصفات واجرات العمل‬
 Misuse of Equipment or tools  Inadequate engineering and / or
 Poor Housekeeping
‫استخدام خاطئ للمعدات او األدوات‬ design
‫النظافة سيئة‬
‫ هندسي‬/‫خلل في التصميم‬
 Inadequate maintenance and / or
 Work environment
inspection
‫بيئة العمل‬
‫خلل في الصياتة والفحص‬
 Inadequate instructions or
 Other ‫اخرى‬ training.
‫التعليمات والتدريب غير كافية‬
 Others
‫اخرى‬
Accident Root Cause ‫السبب الجذري للحادث‬
Preventive Action Taken ‫اإلجراء التصحيحي‬
Recommendations for not repeated the same accident. ‫إجراءات منع تكرار الحادث‬
Report Investigated and Prepared by: ‫القائم باالعداد والتحقيق‬

Date of Report :
Name : ‫االسم‬
‫تاريخ التقرير‬
Designation : ‫الوظيفة‬ Signature : ‫التوقيع‬
Report Reviewed and Approved by: ‫القائم بالمراجعة واالعتماد‬

A) Project Manager : ‫مدير المشروع‬ Signature : ‫التوقيع‬ Date : ‫التاريخ‬
Attached Documents : ‫المرفقات‬

NON CONFORMATION REPORT

Date Modified:
NON CONFORMATION REPORT (NCR) ‫تقرير عدم المطابقة‬

INVOLVED PARTIES ‫االطراف المشتركة‬
Motor Vehicle: ‫مركبات‬ Personal: ‫اشخاص‬ Equipment: ‫معدات‬
Property: ‫ممتلكات‬ Others (Specify): ‫اخرى‬

Date: ‫التاريخ‬ Time: ‫الوقت‬ Location: ‫الموقع‬ Issued to: ‫موجه الى‬ Finished Date: Comments ‫مالحظات‬
‫التاريخ المستهدف النتهاء‬
DESCRIPTION OF NONCONFORMITES (Attach Pictures if Applicable): ‫بيان عدم المطابقة ترفق صور إن امكن‬
CORRECTIVE ACTION: :‫اإلجراء التصحيحي‬
Prepared By: ‫اعداد‬ CM REP: ‫ممثل ادارة المشروع‬
Position: Position:
Signature: Signature:
Date: Date:

DAILY REPORT
Date Modified:
Daily Report ‫التقرير اليومي‬
Project Name ‫اسم المشروع‬

Item ‫بند‬
#. Comment ‫مالحظات‬
Observation /‫الوصف‬ Location / ‫الموقع‬ Time /‫الوقت‬
Prepared by
‫التوقيع‬ ‫االسم‬
‫تم إعداد التقرير بواسطة‬
Safety Manager
‫التوقيع‬ ‫االسم‬
‫مدير السالمة‬

FIRE FIGHTING EQUIPMENT, EMERGENCY LIGHTING

INSPECTION LOG
Document No: SBG-HSE – 010 /01 Revision: 8
Date Modified:
FIRE FIGHTING EQUIPMENT,EMERGENCY LIGHTING INSPECTION LOG

‫ إضاءة الطوارىء و مبيدات قتل الحشرات‬، ‫سجل التفتيش على معدات مكافحة الحريق‬
Facility / FIRE FIGHTING EQUIPMENT ‫معدات مكافحة الحريق‬ Emer. Insect
No. Legend Location FH FW Light Killer
FW Bucket Smoke
‫م‬ ‫القائمة‬ ‫المرفق‬/ Cabinets Drums Fire Ext. ‫إضاءة‬ ‫مبيد‬

)‫سطل (جردل‬ Detector
‫الموقع‬ ‫دوالب خرطوم‬ ‫براميل مياه‬ ‫طفاية الحريق‬ ‫طوارئ‬ ‫حشرى‬
‫المياه‬ ‫كاشف الدخان‬
‫الحريق‬ ‫الحريق‬
Date
Inspected By:
Inspected:
‫تم الفحص بواسطة‬ ‫تاريخ الفحص‬

‫‪FIRE FIGHTING EQUIPMENT, EMERGENCY LIGHTING INSPECTION LOG‬‬
‫‪Document No: SBG-HSE – 010 /02‬‬ ‫‪Revision: 8‬‬

‫رقم الخزان‬ ‫المكان‬

‫سعة الخزان‬ ‫تاريخ الفحص‬
‫مالحظات‬ ‫المحبس‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫القاذف‬
‫‪1‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫الخرطوم‬
‫‪No‬‬ ‫‪Yes‬‬
‫‪4‬‬ ‫‪3‬‬ ‫‪5‬‬ ‫‪2‬‬
‫مالحظات‬ ‫صندوق اإلطفاء‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫غطاء الخزان‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫جسم الخزان‬
‫‪No‬‬ ‫‪Yes‬‬
‫‪6‬‬ ‫مالحظات‬ ‫المضخة‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫البنزين‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫مستوي الماء في الخزان‬
‫‪9‬‬ ‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫سهولة الوصول‬
‫‪7‬‬ ‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫ضغط المياه‬
‫‪No‬‬ ‫‪Yes‬‬
‫‪............................................................................................................................................................................................................‬‬ ‫مالحظات حول خزان الحريق ‪:‬‬
‫‪..........................................................................................................................................................................................................................................................‬‬
‫مهندس السالمة المسؤول‬ ‫اسم الفاحص‬

‫توقيعه‬ ‫توقيعه‬
‫مسؤول قسم االحريق‬ ‫المراقب المسؤول‬
‫توقيعه‬ ‫المستلم ‪:‬‬ ‫‪201‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫بتاريخ ‪:‬‬ ‫استالم المكتب الفني‬
‫‪) 202‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫( تاريخ اإلستبعاد ‪:‬‬ ‫في حال االستبعاد الرجاء ذكر السبب‬
‫‪..........................................................................................................................................................................................................................................................‬‬
‫‪..‬‬
‫مدير السالمة‬ ‫مهندس السالمة المسؤول‬
‫‪/‬‬ ‫‪/‬‬ ‫استالم األرشيف بتاريخ ‪:‬‬
FIRE FIGHTING EQUIPMENT, EMERGENCY LIGHTING INSPECTION LOG

Date Modified:
Check List for Fire Tanks ‫قائمة فحص خزانات الحريق‬

Description ‫الوصف‬
‫مالحظات‬ ‫سهل الوصول‬ ‫البنزين‬ ‫المضخة‬ ‫توصيالت‬ ‫القاذف‬ ‫مستوى الماء‬ ‫جسم الخزان‬ ‫السعة‬ ‫الرقم‬
Comments Easy of access Gasoline Pump Pipe Hoses Water Level Body Tank Capacity No
1
2
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
‫التاريخ‬ ‫مشرف السالمة‬
Date Safety Officer

TOOL BOX MEETING MIMUTES

Date Modified:
TOOL BOX MEETING MIMUTES ‫محضر إجتماع المحاضرات العملية‬

TOPIC:
____________________________________________________________________________________________________________
‫الموضوع‬
‫موعد األجتماع‬ Meeting Time

Place & Date of Meeting: Time Started: Time Started

‫ مكان وتاريخ اإلجتماع‬: ‫البداية‬ ‫النهاية‬
Minutes of Meeting: ‫محضــــــــر االجـتمــــــــــاع‬
Safety Reminder: ‫ نقاط تم التنبيه عليها‬/ ‫رسالة تذكيرية بخصوص السالمه‬
An attendance sheet must be attached ‫يتعين إرفاق كشف الحضور‬
Prepared By: ‫إعــــــــــداد‬
Safety Supervisor: : ‫مشرف الســـــالمه‬

FIRE EXTINGUISHER LOCATION CHECKLIST

Document No: SBG-HSE – 012/01 Revision: 8
Date Modified:
FIRE EXTINGUISHER LOCATION CHECKLIST ‫قائمة فحص مواقع طفايات الحريق‬

Project : ‫المشروع‬ Site: ‫الموقع‬
Fire Extinguisher Check – ‫قائمة فحص طفايات الحريق‬
Location and the fire point number Type Good condition Y / N
Remarks ‫مالحظات‬
‫موقع و رقم نقطة اطفاء الحريق‬ ‫الوزن‬/‫النوع‬ )‫ال‬/‫بحالة جيدة (نعم‬
Name: ‫االسم‬ Position: ‫الوظيفة‬

Signature: ‫التوقيع‬ Date: ‫التاريخ‬

FIRE EXTINGUISHER LOCATION CHECKLIST

Date Modified:
/ / ‫التاريخ‬
/ ‫طفايات‬Extinguishers / ‫حجم‬ Size / 6, 10, 12, 25, 50 ‫النوع‬
‫جسم الطفاية‬ ‫ذراع التشغيل‬ ‫الحامل‬ ‫مسمار األمان‬ ‫الضغط‬ ‫الخرطوم‬
‫االجراء المتخذ‬ ‫حجم‬ ‫سجل الفحص‬ Body Lever Grip Safety pressure Hose ‫الرقم‬
‫سجل الصيانة‬Tag ‫الطفايات‬ Tag Pen
Action Size No
Maintenance Inspection
: ‫مسؤول الوردية‬ : ‫إسم الفاحص‬

: ‫التوقيع‬ : ‫التوقيع‬

NEAR MISS REPORT FORM

Date Modified:
NEAR MISS REPORT FORM ‫تقرير الحادث الوشيك‬

NEAR MISS REPORT ‫تقرير الحادث الوشيك‬
Serial No.:
CLIENT: : ‫المالك‬ PROJECT: : ‫المشروع‬
‫الرقم التسلسلي‬
Date of the event: :‫تاريخ الحدث‬ Time: : ‫الساعة‬
Description of what happened/was observed: ‫وما هي مالحظاتك‬/‫وصف ماحدث‬

……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………...................................................
...................................................................................................
What could happen? Material damage
Injury ‫اصابة‬ Yes No ‫تلف مواد‬
Yes No
‫ما هو المتوقع حدوثه‬
Were persons involved?
‫هل تم إدانة شخص‬
Job:
Surname and Name:‫االسم‬ ‫العمل‬
Site / Equipment involved : ‫هل نتج تأثير على الموقع او المعدات‬
Probable causes: ‫األسباب المحتمله‬
Actions to prevent repetition of the situation: ‫اإلجراء الوقائي لمنع تكرار هذه الحالة‬
Checked and approved by:

Report by: ‫إعداد‬ ‫مراجعة وتصديق‬
Name: ‫االسم‬ Name: ‫االسم‬
Job Title: ‫الوظيفة‬ Job Title: ‫الوظيفة‬
Comments attached ‫ترفق المالحظات‬

CRANE & LIFTING EQUIPMENT
Document No: SBG-HSE – 014 / 01 Revision: 8
Date Modified:
Equipment Name :‫اسم المعدة‬ ) MOBILE CRANE ( ‫الرافعة المتحركة‬

S. N No / ‫رقم الرافعة‬
Manufacture Company ‫الشركة المصنعه‬ Date Of Inspection/ ‫تاريخ الفحص‬
Plat No ‫رقم اللوحة‬ NO.(TUV) ‫رقم الـ‬
Operator Name ‫اسم المشغل‬ company / ‫الشركة‬
Operator TUV: ‫) للمشغل‬TUV(‫رقم الـ‬ Exp. Date (TUV) TUV ‫تاريخ انتهاء‬
License (KSA) No ‫رقم الرخصة السعودية‬ Exp. Date (license equipment) ‫تاريخ انتهاء الرخصة‬
12 Comments/ ‫مالحظات‬ safety latch / ‫قفل األمان‬

11
1
4 No Yes
Comments/ ‫مالحظات‬ Fire extinguisher / ‫طفاية حريق‬
2
No Yes
5
Comments/ ‫مالحظات‬ Safety belt / ‫حزام األمان‬
3
No Yes
7 2
Comments/ ‫مالحظات‬ wipers / ‫مسحات الزجاج األمامي‬
14 9
4
No Yes
Comments/ ‫مالحظات‬ Bottom of hook / ‫حلق الخطاف‬
5
No Yes
6 Comments/ ‫مالحظات‬ Revers alarm / ‫إنذار الرجوع الى الخلف‬
6
No Yes
11 Comments/ ‫مالحظات‬ side mirrors / ‫المرايا الجانبة‬
7
No Yes
13
Comments/ ‫مالحظات‬ Horn / ‫الة التنبيه‬
8
No Yes
Comments/ ‫مالحظات‬ revolving light /‫إضاءة المخاطر‬
3 8 10 9
No Yes
Comments/ ‫مالحظات‬ Tires / ‫اإلطارات‬
10
No Yes
Comments/ ‫مالحظات‬ Back light / ‫إضاءة الخلفية‬
11
No Yes
Comments/ ‫مالحظات‬ Wire Rope / ‫سير البكرة‬
12
No Yes
Comments/ ‫مالحظات‬ outrigger plate / ‫القواعد الخشبية للركائز‬
13
No Yes
Comments/ ‫مالحظات‬ hook / ‫الخطاف‬
14
No Yes
Comments/ ‫مالحظات‬ Oil Leakage / ‫تهريب زيت‬
15
No Yes
Comments / ‫مالحظات‬ Automatic stop for Main hook‫اإليقاف التلقائي للهوك الرئيسي‬ Comments/ ‫مالحظات‬ Load Chart / ‫الرسم البياني للحمل‬
16
No Yes No Yes
..................................................................................................................................................................................................................................... ( Comments ) ‫مالحظات حول الرافعة‬
Signature / ‫توقيعه‬ Safety Officer / ‫مراقب السالمة‬

Signature / ‫توقيعه‬ Safety Engineer / ‫مهندس السالمة المسؤول‬
Signature / ‫توقيعه‬ Operator / ‫إسم المشغل‬
Signature / ‫توقيعه‬ Equipment Dep, response/ ‫مسؤول قسم المعدات‬
) / / : ‫( تاريخ اإلستبعاد‬ ‫ في حال إستبعاد الرافعة الرجاء ذكر سبب اإلستبعاد‬in case the crane excluded, please reason for exclusion ( : (Exclusion Date: / / )
......................................................................................................................................................................................................................................................... .............................................................................................................................
Construction Manage r‫المدير التنفيذي‬ Safety Manager ‫مدير السالمة‬ Safety Engineer ‫مهندس السالمة المسؤول‬
Signature / ‫توقيعه‬ Signature / ‫توقيعه‬ Signature / ‫توقيعه‬
Archive Received Date: / / / / : ‫إستالم األرشيف بتاريخ‬

Date Modified:
Equipment name /‫اسم المعدة‬ ) Tower Crane ( ‫الرافعة البرجية‬
Date of / ‫تاريخ الفحص‬
Manufacture Company ‫الشركة المصنعه‬
inspection
Exp. Date / TUV ‫تاريخ انتهاء‬
TUV No/ TUV ‫رقم الـ‬
(TUV)
Operator Name /‫اسم المشغل‬ Company / ‫الشركة‬
Exp. / ‫ المشغل‬TUV ‫تاريخ انتهاء‬
Operator TUV No/ ‫ للمشغل‬TUV ‫رقم الـ‬
Date (TUV)
Comments/ ‫مالحظات‬ TUV / ‫الرافعة‬Crane
1
No Yes
Comments/ ‫مالحظات‬ / ‫حزام األمان‬safety belt
2
No Yes
2 Comments/ ‫مالحظات‬ TUV/ ‫ السائق‬Operator
3 1 3
No Yes
Comments/ ‫مالحظات‬ / ‫ الخطاف‬hook
4
No Yes
Comments/ ‫مالحظات‬ /‫فحص الكمبيوتر‬computer test
5
No Yes
‫ البوم‬/‫اإليقاف التلقائي للهوك‬
Comments/ ‫مالحظات‬
Automatic stop for/ boom 6
No Yes
8 Comments/ ‫مالحظات‬ ‫ التأريض‬Earth /
7
No Yes
5
Comments/ ‫مالحظات‬ ‫ الذراع‬Trolley Jib /
8
No Yes
4 Comments/ ‫مالحظات‬ /‫ طفاية حريق‬Fire extinguisher
9
No Yes
6 11 Comments/ ‫مالحظات‬ / ‫المسحات‬wipers

10
No Yes
Comments/ ‫مالحظات‬ / ‫قفل األمان‬safety latch
17 11
No Yes
Comments/ ‫مالحظات‬ /‫ حلق الخطاف‬Bottom of hook
12
12 No Yes
Comments/ ‫مالحظات‬ ‫ القاعدة‬Base /
13
No Yes
9 ‫جدول الصيانة‬Maintenance
7 Comments/ ‫مالحظات‬
Schedule /
10 14
No Yes
13 / ‫ الفحص اليومي للمشغل‬Daily
Inspection 15
No Yes
Comments/ ‫مالحظات‬ ‫ تهريب الزيت‬/ Oil Leak
16
No Yes
Comments/ ‫مالحظات‬ / ‫مسمار األمان‬Safety Pin
17
No Yes
................................................................................................................................................................................................................................................ : Comment / ‫مالحظات حول الرافعة‬
Signature / ‫توقيعه‬ Operator/ ‫إسم المشغل‬

Equipment Dep, / ‫مسؤول قسم المعدات‬
Signature / ‫توقيعه‬
response
........................................................................................................................................................................................................................... ....................................................................
Construction Manager‫المدير التنفيذي‬ Safety Manager‫مدير السالمة‬ Safety Engineer‫مهندس السالمة المسؤول‬
/ / : ‫إستالم األرشيف بتاريخ‬ Archive Received Date: / /

Date Modified:
Equipment name /‫اسم المعدة‬ ) Tower Crane ( ‫الرافعة البرجية‬
Manufacture Company ‫الشركة المصنع‬ Date of inspection/ ‫تاريخ الفحص‬
TUV No/ TUV ‫رقم الـ‬ Exp. Date (TUV) / TUV ‫تاريخ انتهاء‬
Operator Name /‫اسم المشغل‬ Company / ‫الشركة‬
Operator TUV No/ ‫ للمشغل‬TUV ‫رقم الـ‬ Exp. Date (TUV) / ‫ المشغل‬TUV ‫تاريخ انتهاء‬
Comments / ‫مالحظات‬ TUV / ‫الرافعة‬Crane
1
No Yes
2 1
3 Comments / ‫مالحظات‬ / ‫حزام األمان‬safety belt
2
No Yes
Comments / ‫مالحظات‬ TUV/ ‫ السائق‬Operator
3
No Yes
Comments / ‫مالحظات‬ / ‫ الخطاف‬hook
4
No Yes
Comments / ‫مالحظات‬ /‫فحص الكمبيوتر‬computer test
5
No Yes
‫ البوم‬/‫اإليقاف التلقائي للهوك‬
Comments / ‫مالحظات‬
8 Automatic stop for/ boom 6
No Yes
Comments / ‫مالحظات‬ ‫ التأريض‬Earth /
7
No Yes
Comments / ‫مالحظات‬ ‫ الذراع‬Luffing Jib /
8
11 No Yes
6 Comments / ‫مالحظات‬ /‫ طفاية حريق‬Fire extinguisher
5 9
No Yes
4
12 Comments / ‫مالحظات‬ / ‫المسحات‬wipers
10
No Yes
Comments / ‫مالحظات‬ / ‫قفل األمان‬safety latch
11
No Yes
Comments / ‫مالحظات‬ /‫ حلق الخطاف‬Bottom of hook
12
No Yes
Comments / ‫مالحظات‬ ‫ القاعدة‬Base /
13
No Yes
10 Comments / ‫مالحظات‬ ‫جدول الصيانة‬Maintenance Schedule /
7 14
No Yes
13 9 Comments / ‫مالحظات‬ / ‫ الفحص اليومي للمشغل‬Daily Inspection

15
No Yes
Comments / ‫مالحظات‬ ‫ تهريب الزيت‬/ Oil Leak
16
No Yes
Comments / ‫مالحظات‬ / ‫مسمار األمان‬Safety Pin
17
No Yes
............................................................................................................................................................................................................................................... : Comment / ‫مالحظات حول الرافعة‬
...............................................................................................................................................................................................................................................................................................
/ / : ‫إستالم األرشيف بتاريخ‬ Archive Received Date: / /

Date Modified:
Equipment name: ‫اسم المعدة‬ (Crawler Crane) ‫الرافعة المجنزرة‬

S. N N.0 / ‫رقم المجنزرة‬
Manufacture Company ‫الشركة المصنعه‬ Date of inspection / ‫تاريخ الفحص‬
Plat No ‫رقم اللوحة‬ Exp. ‫تاريخ انتهاء رخصة السير‬
Operator Name ‫اسم المشغل‬ company / ‫الشركة‬
License (KSA / ‫رقم الرخصة السعودية‬ Exp. Date (TUV) TUV ‫تاريخ انتهاء‬
Comment ‫تاريخ االنتهاء‬
TUV/ ‫ الرافعة‬Crane
‫ مالحظات‬/ Exp / Date 1
No Yes
1 Comment/ ‫مالحظات‬ TUV/ ‫السائق‬ Operator
2
2 3 No Yes
Comment/ ‫مالحظات‬ ‫مسحات الزجاج األمامي‬wipers

3
No Yes
Comment/ ‫مالحظات‬ / ‫ اقفل األمان‬safety latch
4
No Yes
5 Comment/ ‫مالحظات‬ ‫ويرات الرفع‬

4 5
No Yes
1
Comment/ ‫مالحظات‬ ‫وصالت البوم‬
12 6
No Yes
6
Comment/ ‫مالحظات‬ / ‫المرايا الجانبة‬side mirrors
7
No Yes
7 Comment/ ‫مالحظات‬ / ‫الة التنبيه‬Horn
9 No Yes
8
Comment/ ‫مالحظات‬ /‫إضاءة المخاطر‬revolving light

10 No Yes
9
Comment/ ‫مالحظات‬ ‫الجنزير‬

11 10
No Yes
Comment/ ‫مالحظات‬ /‫إضاءة الخلفية‬Back light
11
No Yes
Comment/ ‫مالحظات‬ /‫إنذار الرجوع الى الخلف‬Revers alarm
12
No Yes
14 13 8 Comment/ ‫مالحظات‬ / ‫حزام األمان‬Safety belt
13
No Yes
Comment/ ‫مالحظات‬ /‫طفاية حريق‬Fire extinguisher
14
No Yes
Comment/ ‫مالحظات‬ /‫تهريب الزيت‬Oil Leak
15
No Yes
Comment/ / ‫باطن الخطاف‬ ‫اإليقاف التلقائي للهوك الرئيسي‬
Comment/ ‫مالحظات‬ Comment/ ‫مالحظات‬ ‫الرسم البياني للحمل‬Graph for load
‫مالحظات‬ Bottom of hook Automatic stop for Main hook 16
No Yes No Yes No Yes
/ ‫مؤشر زاوية اإلنحناء‬Indicator angle bend Comment ‫بكرة رص‬ Comment/ ‫ جسم‬/ ‫الخطاف‬
Comment/ ‫مالحظات‬ ‫الهيدروليك‬
Minimum / ‫أقل زاوية‬ / ‫مالحظات‬ ‫الواير‬ ‫مالحظات‬ hook
Maximum / ‫أكبر زاوية‬ NO Yes No Yes No Yes
............................................................................................................................................................................................................................... : Comment / ‫مالحظات حول الرافعة‬
............................................................................................................................................................................................................................................................

TRANSPORT AND HEAVY EQUIPMENT

Date Modified:
EQ. Name : ‫اسم المعدة‬ Loader Type of inspection)‫ شهري‬-‫نوع الفحص (يومي‬
S. N Equipment No. : ‫رقم المعدة‬
Manufacture Company:: ‫الشركة المصنعة‬ Date of inspection:‫تاريخ الفحص‬
No. (TUV) ‫رقم الـ‬ Expiry Date:)TUV(‫تاريخ إنتهاء ال‬
Operator : ‫اسم المشغل‬ Company : ‫الشركة‬
Operator TUV : ‫) للمشغل‬TUV(‫رقم الـ‬ Expiry Date:‫) للمشغل‬TUV(‫تاريخ انتهاء الـ‬
Comments / ‫مالحظات‬ Seatbelt / ‫حزام األمان‬
1
1 13 No Yes
Comments / ‫مالحظات‬ Tires / ‫اإلطارات‬
2
No Yes
12
Comments / ‫مالحظات‬ Reverse Alarm / ‫إنذار الرجوع للخلف‬
3
No Yes
Comments / ‫مالحظات‬ Revolve Light / ‫إضاءة المخاطر‬
4
No Yes
Comments / ‫مالحظات‬ Sides Mirrors / ‫المرايا الجانبة‬
5
No Yes
4
Comments / ‫مالحظات‬ Horn / ‫الة التنبيه‬
6
No Yes
10 9 Comments / ‫مالحظات‬ Wipers / ‫المساحات‬

7
5 3 No Yes
Comments / ‫مالحظات‬ Fire Extinguisher / ‫طفاية الحريق‬
8
No Yes
Comments / ‫مالحظات‬ Front & Back Lights / ‫اإلضاءة األمامية والخلفية‬
9 No Yes
9
Comments / ‫مالحظات‬ Safety Pin / ‫بنوز ومفصالت الذراع والكفة‬ 1

No Yes 0
Comments / ‫مالحظات‬ Oil Leakage / ‫تهريب الزيت‬ 1
No Yes 1
2 Comments / ‫مالحظات‬ Operator TUV / ‫المشغل‬TUV 1
No Yes 2
Comments / ‫مالحظات‬ Equipment TUV / ‫ المعدة‬TUV 1
6 No Yes 3
8 7 Comments / ‫مالحظات‬
Main / ‫سالمة خراطيم الهيدرولك الرئيسية فقط‬
hosepipe 1
4
No Yes
Comments / ‫مالحظات‬ Daily Inspection / ‫الفحص اليومي للمشغل‬ 1
No Yes 5
.................................................................................................................................................................................................... : Comment / ‫مالحظات حول الرافعة‬
...................................................................................................................................................................................................................................................................... .............................................................................................................................
‫المدير التنفيذي‬ ‫مدير السالمة‬ ‫مهندس السالمة المسؤول‬

Construction Manager Safety Manager Safety Engineer
‫توقيعه‬ ‫توقيعه‬ ‫توقيعه‬

Signature Signature Signature


Date Modified:
Equipment Name :‫اسم المعدة‬ Grader Type of inspection)‫ شهري‬-‫نوع الفحص (يومي‬
Plat N.0 ‫رقم اللوحة‬ Exp. License ‫تاريخ انتهاء رخصة السير‬
Operator Name ‫اسم المشغل‬ Company / ‫الشركة‬
Tuv .No Exp. Date (TUV) ‫تاريخ انتهاء‬
Comments
TUV / ‫المعدة‬Grader
‫ مالحظات‬/ 1
No Yes
Comments
‫مالحظات‬/
‫ حزام األمان‬/Safety belt
2
No Yes
Comments
TUV/ ‫ السائق‬Operator
3
2 No Yes
3 1
Comments
Tires / ‫اإلطارات‬
‫مالحظات‬/ 4
No Yes
Comments
Revers alarm / ‫إنذار الرجوع الى الخلف‬
5
6 No Yes
Comments
12 ‫مالحظات‬/
revolving light /‫إضاءة المخاطر‬
6
8 5 No Yes
Comments
side mirrors / ‫المرايا الجانبة‬
7
7 11 No Yes
Comments
Horn / ‫الة التنبيه‬
8
No Yes
Comments
wipers / ‫مسحات الزجاج األمامي‬
9
No Yes
Comments
Fire extinguisher / ‫طفاية حريق‬
10
No Yes
Comments Front Back light / ‫اإلضاءة األمامية والخلفية‬
4 13 ‫مالحظات‬/ & 11
No Yes
10 Comments Nail hinge for Arm and bucket ‫بنوز ومفصالت الذراع والكفة‬
‫مالحظات‬/ and
0 9 12
No Yes
Comments
‫ الشوكة الخلفية‬/ back fork
13
No Yes
Comments
Oil Leak / ‫تهريب الزيت‬
14
No Yes
Comments Daily inspection / ‫الفحص اليومي للمشغل‬
‫مالحظات‬/ (operator) 15
No Yes
Comments
Maintenance sheet / ‫جدول الصيانة‬
16
No Yes
Comments
hoses / ‫سالمة الخراطيم‬
‫مالحظات‬/ 17
No Yes
.................................................................................................................................................................................................................. : Comment / ‫مالحظات حول الرافعة‬
Signature / ‫توقيعه‬ Equipment Dep, response / ‫مسؤول قسم المعدات‬
..............................................................................................................................................................................................................................................................................................
Construction Manager‫المدير التنفيذي‬ Safety Manager / ‫مدير السالمة‬ Safety Engineer ‫مهندس السالمة المسؤول‬


Date Modified:
Equipment name ‫اسم المعدة‬ Ambulance Type Of Inspection)‫ شهري‬-‫نوع الفحص (يومي‬
S. N No. / ‫رقم المعدة‬
Driver Name ‫اسم الساائق‬ Driver License No.‫رقم رخصة السائق‬
License (CAR) No. / ‫رقم رخصة السيارة‬ Exp. Date (license equipment)‫تاريخ انتهاءالرخصة‬
Comments/ ‫مالحظات‬ Maintenance sheet / ‫جدول الصيانة‬

1
No Yes
Comments/ ‫مالحظات‬ Driver license / ‫رخصة السائق‬
2
No Yes
3 Comments/ ‫مالحظات‬ Seatbelt / ‫حزام األمان‬
3
No Yes
Comments/ ‫مالحظات‬ Tires/ ‫اإلطارات‬
6 4
No Yes
Comments/ ‫مالحظات‬ Revers alarm /‫إنذار الرجوع الى الخلف‬
5
No Yes
5 7 Comments/ ‫مالحظات‬ revolving light /‫إضاءة المخاطر‬
6
No Yes
Comments/ ‫مالحظات‬ side mirrors / ‫المرايا الجانبة‬
7
No Yes
11 Comments/ ‫مالحظات‬ Horn / ‫الة التنبيه‬

8
No Yes
9
No Yes
4 Comments/ ‫مالحظات‬ Fire extinguisher /‫طفاية حريق‬
10
No Yes
10 Comments/ ‫مالحظات‬ Front & Back Lights / ‫اإلضاءة األمامية والخلفية‬

11
No Yes
0
9 8 Comments/ ‫مالحظات‬ Oxygen cylinder/ ‫اسطوانة األكسجين‬
12
No Yes
Comments/ ‫مالحظات‬ Mobile Bed Brakes / ‫فرامل سرير النقالة‬
13
No Yes
Comments/ ‫مالحظات‬ First Aid Kit / ‫شنطة اإلسعافات األولية‬
14
No Yes
Daily inspection / ‫الفحص اليومي للمشغل‬
)(operator) 15
No Yes
Comments/ ‫مالحظات‬ Brake /‫الفرامــــل‬
16
No Yes
.......................................................................................................................................................................................................... : Comment / ‫مالحظات حول الرافعة‬
............................................................................................................................................................................................................... ............................................................................................................................. .......................................
Construction Manager / ‫المدير التنفيذي‬ Safety Manager /‫مدير السالمة‬ Safety Engineer / ‫مهندس السالمة المسؤول‬


Date Modified:
Type of )‫ شهري‬-‫نوع الفحص (يومي‬

Equipment Name: ‫اسم المعدة‬ EXCAVATOR inspection
Manufacture Company ‫الشركة المصنعه‬ Date Of Inspection:‫تاريخ الفحص‬
Plat N.0 ‫رقم اللوحة‬ Exp. License ‫تاريخ انتهاء رخصة السير‬
Tuv .No ‫ للمشغل‬Tuv ‫رقم الـ‬ Exp. Date (TUV) TUV ‫تاريخ انتهاء‬
Comments/ ‫مالحظات‬ Excavator TUV/ ‫ الحفار‬TUV
1
No Yes
2 Comments/ ‫مالحظات‬ Safety belt / ‫حزام األمان‬

2
No Yes
1 Comments/ ‫مالحظات‬ Operator/ ‫السائق‬ TUV

3
No Yes
Comments/ ‫مالحظات‬ bucket nail / ‫بنوز الكفة‬
4
No Yes
Comments/ ‫مالحظات‬ Revers alarm / ‫إنذار الرجوع الى الخلف‬
12 5
No Yes
Comments/ ‫مالحظات‬ revolving light / ‫إضاءة المخاطر‬
6
No Yes
Comments/ ‫مالحظات‬ side mirrors / ‫المرايا الجانبة‬
7
No Yes
5 8
No Yes
6
3 No Yes
9
11 Comments/ ‫مالحظات‬ Fire extinguisher /‫طفاية حريق‬
10
No Yes
11
4 No Yes
‫بنوز ومفصالت الذراع والكفة‬
13 Comments/ ‫مالحظات‬
nail and hinge for Arm and bucket 12
No Yes
Comments/ ‫مالحظات‬ Chain / ‫الجنزير‬
13
No Yes
Comments/ ‫مالحظات‬ Oil Leak /‫تهريب الزيت‬
14
No Yes
10 8 9 Comments/ ‫مالحظات‬ Daily inspection (operator)/ ‫الفحص اليومي للمشغل‬
0 No Yes
15
Comments/ ‫مالحظات‬ Maintenance sheet / ‫جدول الصيانة‬

16
No Yes
Comments/ ‫مالحظات‬ Hoses / ‫سالمة الخراطيم‬
17
No Yes
.............................................................................................................................................................................................................. : Comment / ‫مالحظات حول الرافعة‬
Signature / ‫توقيعه‬ Safety Engineer /‫مهندس السالمة المسؤول‬
..............................................................................................................................................................................................................................................................................................
Construction ‫المدير التنفيذي‬

Safety Manager / ‫مدير السالمة‬ Safety Engineer /‫مهندس السالمة المسؤول‬
Manager /


Date Modified:
Equipment Name ‫اسم المعدة‬ Trailer Truck Type Of Inspection)‫ شهري‬-‫نوع الفحص (يومي‬
S. N No. / ‫رقم المعده‬
Tuv.No )Tuv Exp. Date (Tuv ‫تاريخ انتهاء‬
Driver Name ‫اسم الساائق‬ Driver License No.‫رقم رخصة السائق‬
License ( Trailer ) No. / ‫رقم رخصة الساطحة‬ ) Exp. Date License Equipmen) ‫تاريخ انتهاءالرخصة‬
Comments / ‫مالحظات‬ Trailer Truck/ ‫ تريله‬TUV
1
No Yes
Comments / ‫مالحظات‬ Safety belt / ‫حزام األمان‬

2
No Yes
3 2 1
Comments / ‫مالحظات‬ ‫رخصه السائق‬/ Driver license
3
No Yes
6 Comments / ‫مالحظات‬ Tires/ ‫اإلطارات‬
4
No Yes
Comments / ‫مالحظات‬ Revers alarm /‫إنذار الرجوع الى الخلف‬
9 No Yes
5
Comments / ‫مالحظات‬ revolving light /‫إضاءة المخاطر‬

6
No Yes
5 7
Comments / ‫مالحظات‬ side mirrors / ‫المرايا الجانبة‬
7
No Yes
8
11 No Yes
Comments / ‫مالحظات‬ wipers / ‫مسحات الزجاج األمامي‬
9
No Yes
Comments / ‫مالحظات‬ Fire extinguisher /‫طفاية حريق‬ 1
No Yes 0
10 4 Comments / ‫مالحظات‬
Front & Back / ‫اإلضاءة األمامية والخلفية‬
Lights 1
1
0 8 No Yes
Comments / ‫مالحظات‬ diesel Leak /‫تهريب ديزل‬ 1
No Yes 2
Comments / ‫مالحظات‬ Triangle Reflector / ‫المثلث العاكس‬ 1

No Yes 3
Comments / ‫مالحظات‬ First Aid Kit / ‫شنطة اإلسعافات األولية‬ 1

No Yes 4
Comments / ‫مالحظات‬ 1
(
5
No Yes
Comments / ‫مالحظات‬ Brake /‫الفرامــــل‬ 1
No Yes 6
Comments / ‫مالحظات‬ Doors / ‫سالمة األبواب‬ Comments / ‫مالحظات‬ Maintenance sheet / ‫جدول الصيانة‬
1
7
No Yes No Yes
............................................................................................................................................................................................... : Comment / ‫مالحظات حول الرافعة‬

....................................................................................................................... .................................................................................................................................................................................................................

/ ‫توقيعه‬Signature / ‫توقيعه‬Signature / ‫توقيعه‬Signature


Date Modified:
Equipment Name :‫اسم المعدة‬ Rig Machine Type Of Inspection)‫ شهري‬-‫نوع الفحص (يومي‬
Manufacture Company ‫الشركة المصنعه‬ Manufacture Company ‫الشركة المصنعه‬
Num.(Tuv) ‫رقم الـ‬ Plat No ‫رقم اللوحة‬
Operator : ‫اسم المشغل‬ Company:‫الشركة‬
Operator Tuv : ‫) للمشغل‬Tuv(‫رقم الـ‬ Expiry Date:‫) للمشغل‬Tuv(‫تاريخ انتهاء الـ‬

Comments/ ‫مالحظات‬ hoses / ‫سالمة الخراطيم‬

1
No Yes
Comments/ ‫مالحظات‬ Seatbelt / ‫حزام األمان‬
2
No Yes
Comments/ ‫مالحظات‬ ‫اسطوانة تحريك الذراع‬
1 3
3 2 No Yes
Comments/ ‫مالحظات‬ Back weight / ‫الثقل الخلفي‬
4
No Yes
Comments/ ‫مالحظات‬ Revers alarm / ‫إنذار الرجوع الى الخلف‬
5
No Yes
Comments/ ‫مالحظات‬ revolving light /‫إضاءة المخاطر‬
6
No Yes
14 Comments/ ‫مالحظات‬ side mirrors / ‫المرايا الجانبة‬
7
10 No Yes
0 No Yes
8

9
No Yes
Comments/ ‫مالحظات‬ Fire extinguisher /‫طفاية حريق‬ 1
4 9 Comments/ ‫مالحظات‬
No Yes
Front & Back Lights / ‫اإلضاءة األمامية والخلفية‬
0
1
6 No Yes 1
Comments/ ‫مالحظات‬ ‫الرأس الحفارة‬ 1
No Yes 2
7 Comments/ ‫مالحظات‬ Chain / ‫الجنزير‬ 1
11 No Yes 3
Comments/ ‫مالحظات‬ Shutdown Button/ ‫زر اإليقاف في حالة الطوارئ‬
1 8 No Yes
1
4
5 13 12 Comments/ ‫مالحظات‬
1
(operator)
5
No Yes
Comments/ ‫مالحظات‬ Check Wire / ‫فحص الواير‬ 1
No Yes 6
Comments/ ‫مالحظات‬ Maintenance sheet / ‫جدول الصيانة‬ 1
No Yes 7
............................................................................................................................................................................................................ : Comment / ‫مالحظات حول الرافعة‬
..........................................................................................................................................................................................................................................................................................................................................




Date Modified:
Equipment Name ‫اسم المعدة‬ Water Tanker Type of inspection)‫ شهري‬-‫نوع الفحص (يومي‬
S. N Car No. : ‫رقم السيارة‬
Manufacture Company ‫الشركة المصنعه‬ Date of inspection / ‫تاريخ الفحص‬
Tuv ‫رقم الـ‬ License N.o / ‫رقم الرخصة‬
License (Ksa) No./ ‫رقم الرخصة السعودية‬ ) Exp. Date (license Car)‫تاريخ انتهاءالرخصة‬
Driver Name ‫اسم الساائق‬
Comments / ‫مالحظات‬ Safety Doors / ‫سالمة األبواب‬
1
No Yes
Comments / ‫مالحظات‬ Safety belt / ‫حزام األمان‬

2
No Yes
3 2 9 Comments / ‫مالحظات‬ Driver license / ‫رخصة السائق‬
3
No Yes
6 Comments / ‫مالحظات‬ Tires / ‫اإلطارات‬
4
No Yes
Comments / ‫مالحظات‬ Revers alarm / ‫إنذار الرجوع الى الخلف‬
5
No Yes
Comments / ‫مالحظات‬ revolving light / ‫إضاءة المخاطر‬
7 5 No Yes
6
Comments / ‫مالحظات‬ side mirrors / ‫المرايا الجانبة‬

7
1 No Yes
11 8
No Yes
Comments / ‫مالحظات‬ wipers / ‫المساحات‬
9
No Yes
10 Comments / ‫مالحظات‬ Fire extinguisher / ‫طفاية حريق‬ 1
0 No Yes 0
8 Comments/ ‫مالحظات‬ Front & Back Lights / ‫اإلضاءة األمامية والخلفية‬ 1
No Yes 1
4 Comments / ‫مالحظات‬ diesel leak/ ‫تسريب ديزل‬ 1
No Yes 2
Comments / ‫مالحظات‬ Brake /‫الفرامــــل‬ 1
No Yes 3
Comments / ‫مالحظات‬ First Aid Kit / ‫شنطة اإلسعافات األولية‬ 1
No Yes 4
Comments / ‫مالحظات‬ 1
(operator)
No Yes 5
Comments / ‫مالحظات‬ tanker body / ‫سالمة جسم التنك‬ 1

No Yes 6
Comments / ‫مالحظات‬ Maintenance sheet / ‫جدول الصيانة‬ 1
No Yes 7
............................................................................................................................................................................................................ : Comment / ‫مالحظات حول الرافعة‬

............................................................................................................................................................................................................................................................................................


Date Modified:
Name EQ. : ‫اسم المعدة‬ Roller Compactor Type Of Inspection)‫ شهري‬-‫نوع الفحص (يومي‬
Manufacture Company:‫الشركة المصنعة‬ Date Of Inspection : ‫تاريخ الفحص‬
Num.(TUV) ‫رقم الـ‬ Expiry Date:)Tuv(‫تاريخ إنتهاء ال‬
Operator : ‫إسم المشغل‬ Company:‫الشركة‬
Operator TUV :‫) للمشغل‬TUV(‫رقم الـ‬ Expiry Date: ‫) للمشغل‬Tuv(‫تاريخ انتهاء الـ‬
Comments/ ‫مالحظات‬ Equipment TUV/ ‫ المعدة‬TUV
1
2 No Yes
Comments/ ‫مالحظات‬ seatbelt /‫حزام األمان‬

3 6 2
No Yes
11 1
Comments/ ‫مالحظات‬ Operator / ‫المشغل‬TUV
3
No Yes
5 Comments/ ‫مالحظات‬ Tires / ‫اإلطارات‬
4
7 No Yes
11 Comments/ ‫مالحظات‬ Reverse Alarm/ ‫إنذار الرجوع للخلف‬
5
No Yes
Comments/ ‫مالحظات‬ Revolve Light / ‫إضاءة المخاطر‬

6
No Yes
4 Comments/ ‫مالحظات‬ Sides Mirrors/ ‫المرايا الجانبة‬
7
No Yes
12 Comments/ ‫مالحظات‬ Horn/ ‫الة التنبيه‬

8
No Yes
Comments/ ‫مالحظات‬ Wipers /‫المساحات‬

9
No Yes
Comments/ ‫مالحظات‬ Fire Extinguisher/ ‫طفاية الحريق‬
10 8 No Yes
10
9
11
No Yes
Hosepipe /‫فحص خراطيم وصمامات الهيدرولبك‬
Inspection 12
No Yes
Comments/ ‫مالحظات‬ Oil Leakage / ‫تهريب الزيت‬

13
No Yes
Daily Inspection / ‫الفحص اليومي للمشغل‬
(Operator) 14
No Yes
................................................................................................................................................................................................. : Comment / ‫مالحظات حول الرافعة‬
Signature / ‫توقيعه‬ Operator ‫إسم المشغل‬
..............................................................................................................................................................................................................................................................................


Date Modified:
Eq. Name : ‫اسم المعدة‬ Skied Loader Type of Inspection)‫ شهري‬-‫نوع الفحص (يومي‬
No. (Tuv) ‫رقم الـ‬ Expiry Date:)Tuv(‫تاريخ إنتهاء ال‬

Operator: ‫اسم المشغل‬ Company / Subcontractor:‫ المقاول‬/ ‫الشركة‬
Operator Tuv:‫) للمشغل‬Tuv(‫رقم الـ‬ Expiry Date :‫) للمشغل‬Tuv(‫تاريخ انتهاء الـ‬
Manufacture Company:: ‫الشركة المصنعة‬ Date of Inspection:‫تاريخ الفحص‬

Comments / ‫مالحظات‬ Equipment TUV/ ‫ المعدة‬TUV
1
No Yes
Comments / ‫مالحظات‬ Operator TUV / ‫المشغل‬TUV

2
No Yes
2 3
6 1
Comments / ‫مالحظات‬ seatbelt / ‫حزام األمان‬
3
No Yes
Comments / ‫مالحظات‬ Tires / ‫اإلطارات‬
4
No Yes
5 Comments / ‫مالحظات‬ Reverse Alarm / ‫إنذار الرجوع للخلف‬
7 8 No Yes
5
Comments / ‫مالحظات‬ Revolve Light / ‫إضاءة المخاطر‬

6
No Yes
Comments / ‫مالحظات‬ Mirrors / ‫المرايا‬
11 7
No Yes
9
8
No Yes
Comments / ‫مالحظات‬ Safety Bucket / ‫حالة الكفة وتثبيتها‬
4 9
No Yes
Comments / ‫مالحظات‬ Fire Extinguisher / ‫طفاية الحريق‬
10
No Yes
Comments / ‫مالحظات‬ Front & Back Lights / ‫اإلضاءة األمامية والخلفية‬
10 No Yes
11
0 Comments / ‫مالحظات‬ Oil Leakage / ‫تهريب الزيت‬

12
No Yes
Comments / ‫مالحظات‬ Daily Inspection (Operator) / ‫الفحص اليومي للمشغل‬
13
No Yes
..............................................................................................................................................................................................................................................................................

Date Modified:
Equipment name ‫اسم المعدة‬ Diesel Tanker Type of Inspection)‫ شهري‬-‫نوع الفحص (يومي‬
Car No ‫رقم اللوحة‬ Driver Name ‫اسم الساائق‬

Manufacture Company ‫الشركة المصنعه‬ Date of Inspection/ ‫تاريخ الفحص‬
TUV ‫رقم الـ‬ License No / ‫رقم الرخصة‬
Exp. Date License )‫)تاريخ انتهاءالرخصة‬
License (KSA)‫رقم الرخصة السعودية‬
Equipment
/ ‫مالحظات‬
Equipment TUV / ‫ المعدة‬TUV
Comments 1
No Yes
Safety belt / ‫حزام األمان‬

Comments 2
3 2 9
1 No Yes
Driver license / ‫رخصة السائق‬
Comments 3
6 No Yes
Comments 4
No Yes
7 Comments
No Yes
5
13 5 / ‫مالحظات‬
Comments 6
No Yes
12 / ‫مالحظات‬
Comments
7
No Yes
11 Comments
8
No Yes
Comments 9
No Yes
Fire extinguisher /‫طفاية حريق‬
0 Comments 10
4 8
No Yes
Front & Back Lights / ‫اإلضاءة األماميةوالخلفية‬
Comments 11
No Yes
Safety Doors / ‫سالمة األبواب‬
Comments 12
No Yes
‫سالمة جسم التنك‬
Comments 13
No Yes
First Aid Kit / ‫شنطة اإلسعافات األولية‬
Comments 14
No Yes
Daily inspection (operator) / ‫الفحص اليومي للمشغل‬
Comments 15
No Yes
Brake / ‫الفرامــــل‬
Comments 16
No Yes
/ ‫مالحظات‬ Maintenance Sheet / ‫جدول الصيانة‬
Comments 17
No Yes
diesel leakage / ‫تسريب ديزل‬
Comments 18
No Yes

...........................................................................................................................................................................................................................................................................................................
‫ توقيعه‬/ Signature ‫ توقيعه‬/ Signature ‫ توقيعه‬/ Signature

Date Modified:
EQ. Name : ‫اسم المعدة‬ Concrete Pump

S. N Equipment No.:‫رقم المعدة‬
Manufacture Company:‫الشركة المصنعة‬ Date of inspection:‫تاريخ الفحص‬
Comments/ ‫مالحظات‬ Diesel Tank / ‫خزان الديزل‬
1
No Yes
Comments/ ‫مالحظات‬ Battery / ‫البطارية‬

2
No Yes
Comments/ ‫مالحظات‬ Generator Cover / ‫غطاء مولد الكهرباء‬

3
No Yes
Comments/ ‫مالحظات‬ Power Key / ‫مفتاح التشغيل‬

4
No Yes
Comments/ ‫مالحظات‬ Emergency Key / ‫مفتاح الطوارئ‬

5
No Yes
Comments/ ‫مالحظات‬ Earth / ‫التأريض‬

6
No Yes
Comments/ ‫مالحظات‬ Out Rigger/ ‫أرجل التثبيت‬

7
No Yes

8
No Yes
Comments/ ‫مالحظات‬ Electrical Panel / ‫لوحة الكهرباء‬

9
No Yes
Comments/ ‫مالحظات‬ Oil Leakage / ‫تسريب زيت‬

10
No Yes
Comments/ ‫مالحظات‬ Concrete Leakage / ‫انسكابات للخرسانة بمحيط المعدة‬

11
No Yes
Comments/ ‫مالحظات‬ Hydraulic Oil Hoses / ‫خراطيم زيت الهيدروليك‬

12
No Yes
Comments/ ‫مالحظات‬ Diesel Leak/ ‫تسريب ديزل‬

13
No Yes
Comments/ ‫مالحظات‬ Fire Extinguisher /‫طفاية حريق‬

14
No Yes

.................................................................. ....................................... ..................................................................................................................................................................................................


Date Modified:
Name Eq.: ‫اسم المعدة‬ Placing pump Type Of Inspection)‫ شهري‬-‫نوع الفحص (يومي‬
S. N Equipment No.:‫رقم المعدة‬
Manufacture Company:‫الشركة المصنعة‬ Date Of Inspection:‫تاريخ الفحص‬
No. (Tuv) ‫رقم الـ‬ Expiry Date:)Tuv(‫تاريخ إنتهاء ال‬
Comments/ ‫مالحظات‬ Safety Pin /‫وصالت وبنوز تثبيت الذراع‬
1
No Yes
Comments/ ‫مالحظات‬ Hydraulic / ‫الهيدروليك‬
2
No Yes
Comments/ ‫مالحظات‬ Rotation Point / ‫منطقة الدوران‬

1 3
No Yes
3 2 Comments/ ‫مالحظات‬ Motor moving arm / ‫موتور تحريك الذراع‬
4
No Yes
Comments/ ‫مالحظات‬ Guard Rail / ‫حواجز الحماية‬
5
No Yes
Comments/ ‫مالحظات‬ Ladder / ‫سلم الصعود‬
6
No Yes
5 8 Comments/ ‫مالحظات‬ Basic Nail / ‫مسامير القاعدة‬
7
4 No Yes
Comments/ ‫مالحظات‬ Infra Control Unit / ‫وحدة التحكم‬
8
No Yes
Comments/ ‫مالحظات‬ Earth / ‫التأريض‬
9
6 No Yes
Comments/ ‫مالحظات‬ Oil Leakage /‫تسريب زيت الهايدروليك‬
10
No Yes
Comments/ ‫مالحظات‬ Safety Cables / ‫سالمة الكابالت‬
11
No Yes
7 Comments/ ‫مالحظات‬ Safety Hoses / ‫سالمة الخراطيم‬
12
No Yes
Comments/ ‫مالحظات‬ Emergency key / ‫مفتاح الطوارئ‬
13
No Yes
Safety / ‫تأمين أرضية منصة العمل‬
Platform 14
No Yes
...................................................................................................................................................................................................................... : Comment / ‫مالحظات حول الرافعة‬
............................................................................................................................................................................................................................................................


Date Modified:
Type Of )‫ شهري‬-‫نوع الفحص (يومي‬
Eq. Name:‫اسم المعدة‬ Dyane Inspection
S. N N.0 / ‫رقم المعده‬
Tuv .No )Tuv Exp. Date (Tuv ‫تاريخ انتهاء‬
License (Ksa) No.‫رقم الرخصة السعودية‬ ‫ رقم الرخصه‬/ License No.

Operator : ‫اسم السائق‬ )Exp. Date License)‫تاريخ انتهاءالرخصة‬
Seat belt / ‫حزام األمان‬
Comments 1
No Yes
Driver license / ‫رخصه السائق‬
Comments
5 2
No Yes
Tires/ ‫اإلطارات‬
Comments 3
6 No Yes
Revers alarm /‫إنذار الرجوع الى الخلف‬
Comments 4
No Yes
Comments
8 No Yes
5
4 12 Comments
6
No Yes
Comments 7
10 No Yes
wipers / ‫مساحات الزجاج‬
Comments 8
No Yes
Comments 9
11 No Yes
Front & Back Lights / ‫اإلضاءة األماميةوالخلفية‬
Comments 10
No Yes
Brake / ‫الفرامــــل‬
Comments 11
No Yes
Safety Doors / ‫سالمة األبواب‬
Comments 12
No Yes
Oil Leakage / ‫تهريب زيت‬
Comments 13
No Yes
Comments 14
No Yes
Triangle Reflector / ‫المثلث العاكس‬
Comments 15
No Yes
Maintenance sheet / ‫جدول الصيانة‬
Comments 16
No Yes
First aid kit / ‫شنطة اإلسعافات األولية‬
Comments 17
No Yes
...................................................................................................................................................................................................... : Comment / ‫مالحظات حول الرافعة‬

............................................................................................................................................................................... .................................................................................................................................................


Date Modified:
Equipment Name: ‫اسم المعدة‬ Back Hole Loader Type of Inspection)‫ شهري‬-‫نوع الفحص (يومي‬
S. N No / ‫رقم االمعدة‬
Manufacture Company ‫الشركة المصنعه‬ Date of Inspection / ‫تاريخ الفحص‬
Tuv ‫رقم الـ‬ Exp. Date TUV ‫تاريخ انتهاء‬
Tuv .No ‫ للمشغل‬Tuv ‫رقم الـ‬ Exp. Date (TUV) for operator ‫ للسائق‬TUV ‫تاريخ انتهاء‬
‫االمعدة‬Equipment (TUV)
Comments 1
No Yes
/ ‫حزام األمان‬Seat belt
Comments 2
No Yes
‫(المشغل‬TUV) Operator
3 Comments 3
No Yes
/ ‫اإلطارات‬Tires
Comments 4
No Yes
9
/ ‫إنذار الرجوع الى الخلف‬Revers alarm
Comments 5
No Yes
Comments
/‫إضاءة المخاطر‬revolving light
6
No Yes
/ ‫المرايا الجانبة‬side mirrors
7 Comments 7
5 No Yes
/ ‫الة التنبيه‬Horn
Comments 8
No Yes
‫مسحات الزجاج األمامي‬wipers /
Comments 9
13 No Yes
/ ‫طفاية حريق‬Fire extinguisher
Comments 10
No Yes
11 Comments
/ ‫ اإلضاءة األماميةوالخلفية‬Front & Back Lights
11
No Yes
/ ‫ بنوز ومفصالت الذراع والكفة‬Safety Pin
Comments 12
No Yes
‫الكف الخلفية‬
Comments 13
No Yes
/ ‫تهريب الزيت‬Oil Leakage
Comments 14
No Yes
/ ‫مالحظات‬ / ‫الفحص اليومي للمشغل‬Daily inspection
Comments (operator) 15
No Yes
/ ‫سالمة الخراطيم‬Safety Hoses
Comments 16
No Yes
/ ‫جدول الصيانة‬Maintenance Sheet
Comments 17
No Yes

..........................................................................................................................................................................................................................................................................................................................

Date Modified:
Equipment name: ‫اسم المعدة‬ Bulldozer Type of Inspection)‫ شهري‬-‫نوع الفحص (يومي‬
S. N S. N
TUV ‫رقم الـ‬ Exp. Date (Tuv) Tuv ‫تاريخ انتهاء‬
TUV .NO ‫ للمشغل‬TUV ‫رقم الـ‬ Exp. Date (TUV) For Operator ‫ للسائق‬TUV ‫تاريخ انتهاء‬
Equipment (TUV) ‫االمعدة‬
Comments 1
No Yes
2 6
Comments
seatbelt / ‫حزام األمان‬
2
No Yes
Operator (TUV) ‫المشغل‬
Comments 3
7 No Yes
Comments
Chain / ‫الجنزير‬
4
No Yes
Reverse Alarm / ‫إنذار الرجوع للخلف‬
Comments 5
11 No Yes
Revolve Light / ‫إضاءة المخاطر‬
Comments 6
4 13 No Yes
Sides Mirrors / ‫المرايا الجانبة‬
Comments 7
No Yes
Comments 8
No Yes
Wipers / ‫المساحات‬
Comments 9
No Yes
Fire Extinguisher / ‫طفاية الحريق‬
10 9 8 Comments 10
No Yes
0 / ‫مالحظات‬ Front & Back / ‫اإلضاءة األمامية والخلفية‬
Comments Lights
11
No Yes
Safety Pin / ‫بنوز ومفصالت الذراع والكفة‬
Comments 12
No Yes
Torque / ‫ناقل عزم الدوران‬
Comments 13
No Yes
Oil Leakage / ‫تهريب الزيت‬
Comments 14
No Yes
/ ‫مالحظات‬ Daily inspection / ‫الفحص اليومي للمشغل‬
Comments (operator) 15
No Yes
Safety Hoses / ‫سالمة الخراطيم‬
Comments 16
No Yes
Maintenance Sheet / ‫جدول الصيانة‬
Comments 17
No Yes
............................................................................................................................................................................................................................................................................................................................


Date Modified:
Equipment Name: ‫اسم المعدة‬ Dumper Type of Inspection)‫ شهري‬-‫نوع الفحص (يومي‬
S. N No / ‫رقم االمعدة‬
Tuv ‫رقم الـ‬ Exp. Date (TUV) TUV ‫تاريخ انتهاء‬
Tuv .No ‫ للمشغل‬Tuv ‫رقم الـ‬ Exp. Date (TUV) for operator ‫ للسائق‬TUV ‫تاريخ انتهاء‬
/ Comment
Equipment (TUV) ‫االمعدة‬
‫مالحظات‬ 1
1
3 2 No Yes
/ Comment
No Yes
6
/ Comment
Operator (TUV) ‫المشغل‬
No Yes
10 / Comment
0 No Yes
/ Comment
No Yes
5 / Comment
No Yes
/ Comment
9 ‫مالحظات‬
‫زر ايقاف في حالة الطوارئ‬
7
No Yes
11
/ Comment
No Yes
/ Comment
‫حالة الكفة وتثبيتها‬
No Yes
/ Comment
8 ‫مالحظات‬ 10
4 No Yes
/ Comment
Back light / ‫اإلضاءة الخلفية‬
No Yes
/ Comment
Control Panel / ‫لوحة أزرار التحكم‬
No Yes
/ Comment
No Yes
/ Comment Daily inspection / ‫الفحص اليومي للمشغل‬
‫مالحظات‬ (operator) 14
No Yes
............................................................................................................................................................................................................................................................................................................................


Date Modified:
Eq. Name : ‫اسم المعدة‬ Hydraulic Scissor Lift Type of Inspection)‫ شهري‬-‫نوع الفحص (يومي‬
Manufacture Company : ‫الشركة المصنعة‬ Date of Inspection : ‫تاريخ الفحص‬
No. (Tuv) ‫رقم الـ‬ Expiry Date : )TUV(‫تاريخ إنتهاء ال‬
Operator Tuv : ‫) للمشغل‬Tuv(‫رقم الـ‬ Exp. Date (TUV) for operator ‫ للسائق‬TUV ‫تاريخ انتهاء‬
‫مالحظات‬ Tires/ ‫اإلطارات‬
1
No Yes
‫مالحظات‬ ‫نقاط التصبين والرفع‬
2
No Yes
‫مالحظات‬ ‫تأمين بوابة منصة العمل‬

3
No Yes
‫مالحظات‬ ‫وحدة التحكم السفلى و زر الطوارئ‬

4
No Yes
‫مالحظات‬ ‫وحدة التحكم العليا وعصا التوجيه‬

5
No Yes
‫مالحظات‬ ‫قفل مانع اإلنزالق‬

6
No Yes
‫مالحظات‬ ‫مقبض الطوارئ لمضخة الهيدروليك‬

7
No Yes
‫مالحظات‬ ‫صوت التنبيه‬

8
No Yes
‫مالحظات‬ ‫قفل مانع الحركة أثناء الصيانة‬

9
No Yes
‫مالحظات‬ ‫تسريب زيت هيدروليك‬

10
No Yes
‫مالحظات‬ ‫سالمة خراطيم الهيدروليك‬

11
No Yes
‫مالحظات‬ ‫سالمة بساتم الهيدروليك‬

12
No Yes
‫مالحظات‬ ‫حواجز الحمابة من السقوط‬

13
No Yes
‫مالحظات‬ ‫التأريض‬
14
No Yes

response
...........................................................................................................................................................................................................................................................................................................................


Date Modified:
EQ. Name : ‫اسم المعدة‬ BOOMLIFT Type of inspection)‫ شهري‬-‫نوع الفحص (يومي‬
Manufacture ‫الشركة المصنعة‬
Date of inspection : ‫تاريخ الفحص‬
Company:
No. (TUV) ‫رقم الـ‬ Expiry Date : )TUV(‫تاريخ إنتهاء ال‬
)TUV(‫رقم الـ‬
Expiry TUV : ‫) للمشغل‬TUV(‫تاريخ انتهاء الـ‬
Operator TUV:‫للمشغل‬
Comments/ ‫مالحظات‬ Safety Platform / ‫تأمين منصة العمل‬
1
No Yes
Comments/ ‫مالحظات‬ Upper Console / ‫وحدة التحكم العلوية‬
2
No Yes
Comments/ ‫مالحظات‬ ‫مفصل ذراع الرفع‬
3
No Yes
Comments/ ‫مالحظات‬ Extension Boom / ‫ذراع اإلمتداد‬
4
No Yes
Comments/ ‫مالحظات‬ Main Lifting Arm / ‫ذراع الرفع الرئيسي‬
5
No Yes
Comments/ ‫مالحظات‬ / ‫صينية الدوران‬
6
No Yes
Comments/ ‫مالحظات‬ Counter Weight / ‫ثقل اإلتزان‬
7
No Yes
8
No Yes
Comments/ ‫مالحظات‬ Battery / ‫البطاريات‬
9
No Yes
Comments/ ‫مالحظات‬ Wheel Screws / ‫مسامير ربط محور العجالت‬
10
No Yes
Comments/ ‫مالحظات‬ Lower Console / ‫وحدة التحكم السفلية‬
11
No Yes
Comments/ ‫مالحظات‬ Nail Transmission / ‫مسار نقل الحركة‬
12
No Yes
Comments/ ‫مالحظات‬ Boom lift / ‫ذراع الرفع‬
13
No Yes
Comments/ ‫مالحظات‬ ‫مفصل تحريك منصة العمل‬
14
No Yes
...........................................................................................................................................................................................................................................................................................................................


Date Modified:
Eq. Name : ‫اسم المعدة‬ Dumper truck Type of Inspection)‫ شهري‬-‫نوع الفحص (يومي‬
S. N No /‫رقم السيارة‬
Tuv .No / Tuv ‫رقم الـ‬ )TUV Exp. Date (TUV ‫تاريخ انتهاء‬
License (KSA) N ‫رقم الرخصة السعودية‬ (Exp. Date license equipment) ‫تاريخ انتهاءالرخصة‬
Driver Name ‫اسم الساائق‬ License N.o
Trailer Truck/ ‫ تريله‬TUV
Comments 1
No Yes
015-05trailer / ‫مالحظات‬
Comments
inspection.docx 2
No Yes
‫رخصه السائق‬/ Driver license
2 Comments 3
No Yes
3 1
Comments 4
No Yes
6
/ ‫مالحظات‬ Revers /‫إنذار الرجوع الى الخلف‬
Comments alarm 5
No Yes
7
Comments
6
No Yes
Comments 7
No Yes
Comments 8
11 No Yes
Comments 9
No Yes
Comments 10
11 4 No Yes
/ ‫مالحظات‬ Back light /‫إضاءة الخلفية‬
11 Comments front light/ ‫اإلضاءة األمامية‬ 11
9 8 No Yes
diesel Leak /‫تهريب ديزل‬
Comments
0 No Yes
12
Brake /‫الفرامــــل‬
Comments 13
No Yes
/ ‫مالحظات‬ First Aid / ‫شنطة اإلسعافات األولية‬
Comments Kit 14
No Yes
/ ‫مالحظات‬ Daily / ‫الفحص اليومي للمشغل‬
Comments )inspection (operator) 15
No Yes
Comments / ‫مالحظات‬ Triangle Reflector / ‫المثلث العاكس‬ Comments / ‫مالحظات‬ ‫سالمة جسم القالب‬ Doors / ‫سالمة األبواب‬
Comments 16
No Yes No Yes No Yes
/ ‫مالحظات‬ Maintenance / ‫جدول الصيانة‬
Comments sheet 17
No Yes

response
.........................................................................................................................................................................................................................................................................................................................

Date Modified:
:Equipment Name ‫اسم المعدة‬ Fire Fighting Tanker Type of Inspection )‫ شهري‬-‫نوع الفحص (يومي‬
S. N No /‫رقم السيارة‬
Tuv .No / Tuv ‫رقم الـ‬ )TUV Exp. Date (TUV ‫تاريخ انتهاء‬
Driver Name ‫اسم الساائق‬ )Exp. Date (licens) ‫تاريخ انتهاءالرخصة‬
License (KSA) N ‫رقم الرخصة السعودية‬ Overall Assessment / ‫التقييم العام‬

Trailer Truck/ ‫ تريله‬TUV
Comments 1
No Yes

Comments 2
No Yes
‫رخصه السائق‬/ Driver license
Comments 3
No Yes
3 2 1 Comments 4
No Yes
Revers alarm /‫إنذار الرجوع الى الخلف‬
Comments 5
6 No Yes
Comments 6
No Yes
7 5
Comments 7
No Yes
Comments 8
No Yes
11 wipers / ‫مسحات الزجاج األمامي‬
Comments 9
No Yes
13
Comments 10
No Yes
/ ‫مالحظات‬ Back light /‫إضاءة الخلفية‬
Comments front light/ ‫اإلضاءة األمامية‬
10 11
No Yes
diesel Leak /‫تهريب ديزل‬
44 Comments
No Yes
12
0 8
Brake /‫الفرامــــل‬
Comments 13
No Yes
First Aid Kit / ‫شنطة اإلسعافات األولية‬
Comments 14
No Yes
Hoses case /‫حالة الخراطيم‬
Comments 15
No Yes
‫حالة القواذف‬
Comments 16
No Yes
‫وحدة التحكم‬ / ‫مالحظات‬

Comments / ‫مالحظات‬ Comments / ‫مالحظات‬ ‫وصالت الخراطيم‬ Maintenance sheet / ‫جدول الصيانة‬
Control unit/ Comments
NO Yes No Yes No Yes

..................................................................................................................................................................................................................................................................................................................... .......


Date Modified:
EQ. Name : ‫اسم المعدة‬ Grinder Type of Inspection)‫ شهري‬-‫وع الفحص (يومي‬
S. No. Equipment No. : ‫رقم المعدة‬
Company : ‫الشركة‬ Date of Inspection:‫تاريخ الفحص‬
Comments/ ‫مالحظات‬ Safety Cables / ‫سالمة الكابالت‬
1
5 Not Ok Ok
Comments/ ‫مالحظات‬ Control Knob / ‫وجود يد التحكم‬

2
4 No Yes
Comments/ ‫مالحظات‬ Start Button / ‫زر التشغيل‬

3
No Yes
Device Body / ‫حالة جسم األداة‬

Case 4
3 Not Ok Ok
Comments/ ‫مالحظات‬ Case Of Engine / ‫حالة الموتور‬

1 5
Not Ok Ok
Comments/ ‫مالحظات‬ Guard Of Disk / ‫غطاء القرص‬

6
No Yes
Comments/ ‫مالحظات‬ Case Of Disk / ‫حالة القرص‬

2 7
Not Ok Ok
7 6
Signature / ‫توقيعه‬ Operator Name/ ‫إسم المشغل‬
..................................................................................................................................................................................................................................................................... ....................................................................................... ...
Construction Manager /‫المدير التنفيذي‬ Safety Manager /‫مدير السالمة‬ Safety Engineer /‫مهندس السالمة المسؤول‬

Date Modified:
EQ. Name : ‫اسم المعدة‬ Hilti Type of Inspection )‫ شهري‬-‫نوع الفحص (يومي‬
S. No Equipment No. : ‫رقم المعدة‬
Company : ‫الشركة‬ Date of Inspection:‫تاريخ الفحص‬
/ ‫مالحظات‬ Safety / ‫سالمة الكابالت‬

Comments Cables
1
4 Not Ok Ok
/ ‫مالحظات‬ Control / ‫وجود يد التحكم‬

5 Comments Knob
2
6 No Yes
Start Button / ‫زر التشغيل‬
Comments
3
No Yes
/ ‫مالحظات‬ Device / ‫حالة جسم األداة‬

Comments Body Case
4
Not Ok Ok
3
2 / ‫مالحظات‬ Case Of / ‫حالة الموتور‬
Comments Engine
5
1
Not Ok Ok
/ ‫مالحظات‬ Case Of / ‫حالة وجودة المسمار‬

Comments Pin
6
Not Ok Ok
............................................................................................................................................................................................................................................................................ ................................................

Date Modified:
Eq. Name : ‫اسم المعدة‬ Cutting Machine Type of Inspection )‫ شهري‬-‫نوع الفحص (يومي‬
Manufacture Company:: ‫الشركة المصنعة‬ Date of Inspection:‫تاريخ الفحص‬
No. (Tuv) ‫رقم الـ‬ Expiry Date:)TUV(‫تاريخ إنتهاء ال‬
Comments/ ‫مالحظات‬ ‫ القرص‬/ Disc
1
3 No Yes
Comments/ ‫مالحظات‬ ‫ جسم المعده‬/ Body machine

3
No Yes
2
5 Comments/ ‫مالحظات‬ ‫ المقبض‬/‫ا‬Handel
4
No Yes
Comments/ ‫مالحظات‬ ‫ السلك الكهربائي‬/ Electric wire

5
No Yes
Comments/ ‫مالحظات‬ ‫ االمان‬/ ‫ حاجز‬/ security guard
4 6
No Yes
1
6
Comments / ‫مالحظات‬ ‫ مفتاح الربط‬/ Spanner

7
No Yes
‫التأكد من استخدام الديسك المناسب لكل عمليه قطع‬

Be sure to use the appropriate disk
8
No Yes
‫ الخاص بكل منشار أن يكون مطابق مع نوعيه الديسك المستخدم‬RPM ‫التاكد من‬
Make sure the RPM of all saw to be identical with the disc used
9
No yes
Comment: ……………………………………………………………………………………………………………….…………………………………………………………………. / ‫مالحظات حول الرافعة‬
Signature / ‫توقيعه‬ Operator ‫إسم المشغل‬



GAS CUTTING APPARATUS

Date Modified:
PROJECT SITE SAFETY COLOR CODING ‫لون كود السالمة الخاص بموقع المشروع‬
For the Month of..................................... is.............................
. ....................‫ هو كود اللون‬.........................‫نأمل التنبيه على أن لون كود السالمة عن شهر‬
It is certified that I have inspected, maintained and repaired the following items, equipments, tools, etc
under my charges /responsibility and color coded there as................. For Month
......... ‫ لشهر‬............. ‫أشهد أنا الموقع أدناه بأنني قمت بالتفتيش علي المعدات واألدوات إلخ تحت مسئوليتي ووضع رمز اللون‬
The following are the items inspected. ‫وفيما يلي بيان بالبنود التي تم التفتيش والكشف عليها‬
Remarks
‫مالحظات‬
GAS CUTTING APPARATUS ‫اجهزة القطع بالغاز‬ Not
OK OK
i. Regulators ‫المنظمات‬
ii. Gauges ‫العدادات‬
iii. Hoses ‫الخراطيم‬
iv. Torches ‫البطاريات‬
v. Flashback Arrester ‫صمام عدم الرجوع‬
vi. Trolley with Chain ‫تروللي مع الجنزير‬
vii. Fire Extinguisher ‫طفايات الحريق‬
viii. Cables ‫الكابالت‬
ix. Clamps ‫مشابك التثبيت‬
x. GFCI ‫قاطع التسرب األرضي‬
xi. Grinder ‫الصاروخ‬
xii. Extension Cables ‫كابالت التوصيل‬
xiii. Grounding System ‫التوصيل األرضي‬
xv. Cylinder body ‫جسم االسطوانه‬
xvi. Others (specify): (‫أخرى ( حدد‬
xvii. Equipment Details: ‫بيانات المعدة‬
Model No:
Type: ‫النوع‬ KSA No.: ‫رقم‬
‫رقم الموديل‬
Calibration No. ‫رقم‬

Valid Up to. ‫صالحة حتى‬
‫المعايرة‬
xvii. Welder Details: ‫بيانات اللحام‬
Name : ‫االسم‬ Comp.# ‫الشركة‬

Certificate No.
Valid Up to: ‫صالحة حتى‬
‫رقم الشهادة‬
Signature: Date:
Remarks:

GAS CUTTING APPARATUS – Welding Machine

Date Modified:
EQ. Name : ‫اسم المعدة‬ Welding Machine

Company: ‫الشركة‬ Date of inspection:‫تاريخ الفحص‬
Operator TUV : ‫) للمشغل‬TUV(‫رقم الـ‬ Expiry Date:‫) للمشغل‬TUV(‫تاريخ انتهاء الـ‬
Safety Cables/‫سالمة األسالك الكهربائية‬
6 4 Comments 1
No Yes
3 Comments
Earth/‫التأريض‬
2
No Yes
5 / ‫مالحظات‬ Safety Connection ‫سالمة نقاط توصيل الكابالت‬
Comments Points/ 3
No Yes
‫سالمة مقبس الكهرباء‬Safety Electricity Socket /
Comments 4
No Yes
/ ‫مالحظات‬ Safety Electricity ‫سالمة مؤشر درجة الكهرباء‬
Comments Indicator/ 5
No Yes
Control Handle / ‫يد التحكم‬
Comments 6
No Yes
/ ‫مالحظات‬ Safety Temperature /‫سالمة مؤشر درجة الحرارة‬

Comments Indi cator
1 7
No Yes
Emergency Stop/‫زر أيقاف في حالة الطوارئ‬
Comments 8
No Yes
Fire Extinguisher/‫طفاية حريق‬
Comments 9
No Yes
/ ‫مالحظات‬ ‫مؤشر تحذير ارتفاع درجة الحرارة بالماكينة‬/High

Comments temperature warning indicator 10
No Yes
/ ‫مالحظات‬ Oil )‫تسريب ديزل ( للماكينات التي تعمل بالديزل‬

Comments Leakage/
11
No Yes

/ ‫توقيعه‬Signature Safety Officer / ‫مراقب السالمة‬
/ ‫توقيعه‬Signature Safety Engineer /‫مهندس السالمة المسؤول‬
/ ‫توقيعه‬Signature Operator Name/ ‫إسم المشغل‬
/ ‫توقيعه‬Signature Equipment Dep, response/ ‫مسؤول قسم المعدات‬
............................................................................................................................................................................................................................................................................................................................

ELECTRICAL OPERATED HAND POWER TOOLS

Date Modified:
PROJECT SITE SAFETY COLOR CODING ‫لون كود السالمة الخاص بموقع المشروع‬
For the Month of..................................... is.............................
. ....................‫ هو كود اللون‬.........................‫نأمل التنبيه على أن لون كود السالمة عن شهر‬
It is certified that I have inspected, maintained and repaired the following items, equipment’s, tools,
etc. under my charges /responsibility and color coded there as........................ For Month..........................
......... ‫ لشهر‬............. ‫أشهد أنا الموقع أدناه بأنني قمت بالتفتيش علي المعدات واألدوات إلخ تحت مسئوليتي ووضع رمز اللون‬
The following are the items inspected. ‫وفيما يلي بيان بالبنود التي تم التفتيش والكشف عليها‬
Remarks
ELECTRICAL OPERATED HAND POWER TOOLS ‫مالحظات‬
‫اآلالت و العدد اليدوية التي تدار بالكهرباء‬ OK
Not
OK
i. Safety Guard ‫حاجز السالمة‬/‫وقاء‬
ii. Power Cables ‫األسالك الكهربائية‬
iii. Clamp ‫ مشبك‬/ ‫ماسك‬
iv. Grounding System: ‫نظام التوصيل األرضي‬
v. Extension Cables ‫كابالت التوصيل‬
vi. Fire Extinguisher ‫طفاية الحريق‬
vii. Others (specify): )‫اخرى (حدد‬
viii. Equipment Details: ‫بيانات المعدة‬
Type: ‫النوع‬ Model No: ‫رقم الموديل‬ KSA No.: ‫رقم‬
Calibration No. ‫رقم المعايرة‬ Valid Up to. ‫صالحة حتى‬
viii. User Details: ‫بيانات المستخدم‬
Name : ‫االسم‬ Comp.# ‫الشركة‬
Certificate No. ‫رقم‬

Valid Up to: ‫صالحة حتى‬
‫الشهادة‬
Signature: Date:
Remarks: ‫مالحظات‬

CRANE SET-UP CHECK LIST

Date Modified:
CRANE SET-UP CHECK LIST ‫قائمة الفحص قبل تشغيل الرافعة‬

Site: ‫الموقع‬: Date: ‫التاريخ‬
Crane Company Capacity
‫شركة الرافعة‬ ‫الوزن المسموح‬
Crane Operator Type
‫مشغل الرافعة‬ ‫نوع الرافعه‬

License / Permit Crane ID
‫تصريح العمل \ الرخصة‬ ‫رقم الرافعة‬
№ Requirements ‫المتطلبات‬ Yes No Comment
1 Rigging study correct and approved ‫تجهيز خطة التحميل واعتمادها‬
2 Rigger / Banksman Competent ‫موجه ومسؤل التحميل للرافعة مؤهل‬
3 Correct PPE worn ‫إرتداء مهمات السالمة الشخصية المناسبة‬
4 Ground suitable and level for lift ‫اتزان واستواء التربة‬
5 Out riggers fully extended ‫األرجل ممتدة بشكل صحيح وكامل‬
Outrigger pads in good condition and used correctly
6
‫عوارض خشبية تحت األرجل في حالة جيدة واستخدمت بشكل صحيح‬
7 Wheels off the ground ‫العجالت بعيده عن االرض‬
8 Crane slewing area - barrier in place ‫توفرحواجز حول منطقة الدوران‬
9 Valid test certificate for crane ‫شهادة فحص للرافعة سارية المفعول‬
Valid test certificate for lifting attachments i.e. Chains, slings,
10
clamps etc. ‫شهادة فحص سارية المفعول لمعدات الرفع مثل السالسل و الحبال الخ‬
11 Correct crane load chart available ‫توفر رسم توضيحي لتحمل الرافعة‬
12 Tag lines used ‫إستخدام حبل لتوجية الحمل‬
Weight of the load to be lifted known
13
‫معرفة وزن الحمل والتحقق من مالئمة وزن الحمل لقدرة الرافعه‬
All loose lifting equipment stored correctly
14
‫جميع األجزاء غير المستخدمة تم تخزينها بشكل سليم‬
Safe load indicator / alarm fitted and working
15
‫أجهزة إنذار للتنبية بزيادة الحمل تعمل بشكل جيد‬
Slinging / rigging correct prior to lift
16
‫قبل بدء عملية الرفع تواجد رجل األشارة‬
17 Crane operator competent ‫مشغل الرافعة مؤهل‬
18 Limit switch ‫مفتاح االمان‬
Details of the person’s conducting the check ‫معلومات الشخص الذي قام بالفحص‬
Compa
Job Title ‫مسمى الوظيفة‬ Name ‫االسم‬ Signature ‫التوقيع‬
ny ‫الشركة‬
Crane Operator ‫مشغل‬
Rigger / Banksman
‫الموجه \ مسئول التحمل‬
HSE Officer

EMERGENCY CONTACTS LIST

Date Modified:
EMERGENCY CONTACTS ‫التواصل في حاالت الطوارئ‬

Site address: ‫عنوان الموقع‬ Tel No: ‫رقم الهاتف‬
Contracts Manager : Deputy :
‫مدير الموقع‬ ‫نائب المدير‬
Tel No. ‫رقم الهاتف‬ Tel No. ‫رقم الهاتف‬
LOCAL AUTHORITIES ‫السلطات المحلية‬
Fire ‫الحريق‬ 998 or 911

Police ‫الشرطة‬ 999 or 911
Ambulance ‫اإلسعاف‬ 997 or 911
Hospital A&E Dept. ‫المستشفى‬
STATUTORY AUTHORITIES ‫الجهات الحكومية‬/ ‫السلطات القانونية‬
Electricity & Water
‫الكهرباء والمياة‬
Telecom ‫اإلتصاالت‬
Other ‫اخرى‬
ENFORCING AUTHORITIES ‫فرض السلطات‬

Health & Safety &Security
‫الصحة و السالمة واالمن‬
SBG Environment Agency
‫وحدة البيئة في مجموعة بن الدن‬
Other Out of Hours Contacts ‫التواصل في ساعات خارج العمل‬

Tel No.
Position ‫الوظيفة‬ Name ‫االسم‬ ‫رقم الهاتف‬
Project Manager
‫مدير عام المشروع‬
Logistic Manager
‫مدير اللوجيستك‬
Construction Manager
‫المدير اإلنشائي‬
Site Manager
‫مدير الموقع‬
Project HSE Manager
‫مدير السالمة بالموقع‬
Scaffold Supervisor
‫المشرف على السقاالت‬
MEP Engineer
‫المهندس الكهربائي والمكانيكي‬
Other ‫اخرى‬

HAND, POWER, PNEUMATIC &CARTRIDGE
OPERATED TOOLS SAFETY CHECKLIST

Date Modified:
HAND, POWER, PNEUMATIC & CARTRIDGE OPERATED TOOLS SAFETY

CHECKLIST
‫فحص سالمة األدوات التي تعمل بالهواء المضغوط والطاقة و المعدات اليدوية‬
Sl. # Items ‫البند‬ Yes No
1 Tools Operators Certificate of Competency ‫شهادة تاهيل لمشغلي االالت واالدوات‬
2 Log Book for Issued and Returned Tools ‫سجل لخروج وإعادة األدوات‬
3 Proper Storage of Tools ‫تخزين مناسب لالدوات‬
4 Operators Personal Protective Equipments (PPE) ‫مهمات السالمة الشخصية للمشغلين‬
6 Operators/ Workers Hearing Protection ‫وسائل حماية السمع للمشغلين‬
7 Plug into Ground Fault Circuit Interrupter (GFCI) ‫المعدة متصلة بكاشف تسرب االرضي‬
3 Wire Ground Cord and 3 Prong Ground Plug
8
‫ثالثة اسالك في كايبل الكهرباء و ثالثة فتخات في الفيش‬
Double Insulated Tools Shall Bear a UL, FM or Other Recognized Testing
9
Laboratory ‫أدوات مزودة بعزل مزدوج للقدرة على التحمل معتمدة من جهة موثوقه‬
10 Proper Tool Guards ‫تواجد حاجز لألدوات‬
Safety Whip Checks to Secure Pneumatic Tools
11
‫سالمة الخراطيش للتأكد من سالمة األدوات التي تعمل بالهواء المضغوط‬
12 Tool Rest Adjustment ‫أداة إعادة الضبط‬
13 Shut Off Switch/Dead Man Controls ‫مفتاح لفصل الجهاز والتحكم بة في حالة وجود خطر‬
14 Correct Grinder Disc Speeds ‫تصحيح سرعة قرص الصاروخ‬
15 No Damaged Hand Tools ‫المعدات اليدوية سليمة‬
16 Hand tools Proper Usage ‫المعدات اليدوية مناسبة لإلستخدام‬
17 Cable/Hose Connections Conditions ‫توافر الكابالت والخراطيم مع اماكن اتصالها‬
18 Cords Overall Conditions ‫الحالة العامة لربط الخراطيم و الوصالت جيدة‬
19 Hand Tools Overall Conditions ‫األدوات اليدوية توافق جميع االشتراطات‬
20 Barricades and Warning Signs in Place ‫توافر حواجز وعالمات التحذير‬
21 No Home Made Tools ‫التوجد أدوات من صناعة العمال‬
22 Pneumatic Hoses Secured ‫تأمين خراطيم الهواء المظغوط‬

HAND, POWER, PNEUMATIC &CARTRIDGE
OPERATED TOOLS SAFETY CHECKLIST

Date Modified:
EQ. Name : ‫اسم المعدة‬ Compressor - ‫الكمبرسور‬

Company : ‫الشركة‬ Date of inspection:‫تاريخ الفحص‬
Comments/ ‫مالحظات‬ Safety Air hosepipe /‫تأمين خراطيم الهواء المظغوط‬
1
No Yes
Comments/ ‫مالحظات‬ Case of Cover /‫حالة غطاء الكمبروسور‬

2
No Yes
Comments/ ‫مالحظات‬ Operation Control Panel/ ‫لوحة وأزرار التشغيل‬

3
No Yes
Comments/ ‫مالحظات‬ Case of Engine/‫حالة المحرك‬

4
No Yes
Comments/ ‫مالحظات‬ Case Of Fan/‫حالة المروحة‬

5
No Yes
Comments/ ‫مالحظات‬ Emergency Key/‫زر االيقاف في حالة الطوارئ‬

6
No Yes
Comments/ ‫مالحظات‬ Fire Extinguisher/‫طفاية الحريق‬

7
No Yes
Comments/ ‫مالحظات‬ Case Of Tires/‫حالة اإلطارات‬

8
No Yes
Comments/ ‫مالحظات‬ Case Of Filters/‫حالة الفالتر‬

9
No Yes
Comments/ ‫مالحظات‬ Oil Leakage/‫وجود تسريبات‬

10
No Yes
Comments/ ‫مالحظات‬ Conveyors/‫السيور‬

11
No Yes

............................................................................................................................................................................................................................................................................................................................

‫‪HAND, POWER, PNEUMATIC &CARTRIDGE‬‬
‫‪OPERATED TOOLS SAFETY CHECKLIST‬‬
‫‪Document No: SBG-HSE – 020/2‬‬ ‫‪Revision: 8‬‬

‫اسم المعدة‬ ‫‪Sanding Blasting Machine‬‬

‫‪S. N‬‬ ‫رقم المعدة‬
‫الشركة المصنعة‬ ‫تاريخ الفحص‬
‫رقم الـ ‪TUV‬‬ ‫تاريخ انتهاء الـ ‪TUV‬‬
‫مالحظات‬ ‫قمع التعبئة‬
‫‪1‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫صمام المخرج‬

‫‪2‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫صمام الغلق‬

‫‪3‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫اإلطارات‬
‫‪4‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫مسند‬
‫‪5‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫بنز الغلق‬

‫‪6‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫صمام المدخل‬

‫‪7‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫كاتم الصوت‬

‫‪8‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫كابل أمان الخرطوم‬

‫‪9‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫قناع واق كامل وسليم األجزاء‬

‫‪10‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫قفاز مطاطي‬

‫‪11‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫محبس التحكم في الهواء‬

‫‪12‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫فلتر‬
‫‪13‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات حول االمعدة ‪.................................................................................................................................................................................................................................................. :‬‬
‫مسؤول قسم المعدات‬ ‫فني المعدات‬
‫توقيعه‬ ‫المستلم‬ ‫‪/‬‬ ‫‪/‬‬ ‫بتاريخ ‪:‬‬ ‫استالم المكتب الفني‬
‫)‬ ‫‪/‬‬ ‫‪/‬‬ ‫( تاريخ اإلستبعاد ‪:‬‬ ‫في حال االستبعاد الرجاء ذكر السبب‬
‫‪.............................................................................................................................................................................................................................................................................................................................‬‬
‫‪/‬‬ ‫‪/‬‬ ‫استالم األرشيف بتاريخ ‪:‬‬

LADDER SAFETY CHECKLIST

Date Modified:
LADDER SAFETY CHECKLIST ‫قائمة فحص سالمة السلم‬

Y N
 Are all the rungs, cleats, or steps in good condition?
‫هل درجات السلم بحالة جيدة؟‬ □ □
 Are the side rails intact without any cracks, bends, or breaks?
‫ اإلنحناءات و الكسور؟‬,‫هل الحواجز الجانبية سليمة و خالية من التشققات‬ □ □
 Do the rungs, cleats, or steps fit into the side rails?
‫هل الدرجات و األوتاد متوافقة مع الجواجز الجانبية؟‬ □ □

 Is the ladder free of corrosion? ‫هل السلم خالي من الصدأ و التأكل؟‬ □ □
 Are the ladder's hardware and fittings secure and undamaged?
‫هل األجزاء الثابتة و التجهيزات للسلم مثبتة بشكل جيد وغير تالفة؟‬ □ □
 Do moveable parts operate freely without binding or excessive play?
‫غير الثابتة تعمل بال معوقات ؟‬/ ‫هل األجزاء المتحركة‬ □ □
Are damaged ladders removed from service and marked "Do not use"? 
‫هل الساللم الغير آمنة او تالفة تم إيقاف العمل عليها ووضع عالمة "غير صالح لإلستخدام "؟‬ □ □
 Is laddering suitable for the work being carried out?
‫هل السلم يتناسب مع العمل الذي سوف يستخدم من أجله؟‬ □ □
 Is the ladder strong enough for the intended use? (Weight of employee and tools equipment
less than ladder rating). ( ‫هل قوة تحمل السلم كافية للغرض الذي سوف يستخدم من أجله؟ (وزن العامل واألدوات‬ □ □
‫والمعدات أقل من الوزن التقديري للسلم‬
 Is the ladder long enough for the intended use?‫هل طول السلم كافي للعمل بأمان؟‬ □ □
 The users waist should not rise above the top step or top of handrail
‫صدر (وسط) المستخدم يجب ان اليرتفع فوق أعلى درجة أو أعلى دربزين‬ □ □
 Does the ladder have non-slip safety feet in good condition?
‫هل يوجد في السلم مانع لإلنزالق لتأمين القدمين و يكون بحالة جيدة؟‬ □ □
 Are workers instructed to place step ladders away from unlocked doors?
‫هل تم التنوية للعمال بوضع السلم بعيدا عن األبواب الغير مغلقة؟‬ □ □
 Is the danger from electric shock considered when using a metal or wet wooden LADDER?
‫هل تم التركيز على مخاطر الصعقات الكهربائية عند إستخدام الساللم المعدنية او الخشبية المبللة؟‬ □ □
 Is the ladder placed on a flat level surface? ‫هل تم وضع السلم على سطح مستوي؟‬ □ □
 Do workers bring supplies up ladder using tool belts?
‫هل يستخدم العمال أحزمه لحمل األدوات الستخدامها عند العمل علي السلم؟‬ □ □
 Is the ladder moved frequently to avoid overstretching? ‫هل يتم تحريك السلم بشكل منتظم لتجنب التلف؟‬ □ □
 Is only one person permitted on the ladder at a time? ‫السماح لعامل واحد فقط للعمل على السلم في وقت واحد؟‬ □ □
 Are tags/labels available to identify unsafe LADDER s and are they removed from service
immediately? ‫ملصقات لتحديد السلم غير السليم وهل يستبعد من الموقع فوراً؟‬/‫هل تتوفر بطاقات‬ □ □
 Are ladder s subject to a daily pre-use check? ‫هل الساللم تخضع للفحص اليومي قبل اإلستخدام؟‬ □ □
 Are documented inspections carried out on ladders regular intervals?
‫هل عمليات الفحص المنفذة على الساللم تتم علي فترات منتظمة وتم توثيقها؟‬ □ □
 Are employees instructed on the safe use of ladders? ‫هل تم الشرح للعمال عن السالمة عند إستخدام الساللم؟‬ □ □
Each “No” answer indicates that corrective action must be taken

EXCAVATION DAILY INSPECTION SHEET

Date Modified:
EXCAVATION DAILY INSPECTION SHEET ‫الفحص اليومي للحفريات‬

Name of project: ‫المشروع‬
Site: ‫الموقع‬
INSPECTED BY
DATE: ‫التاريخ‬ SITE : ‫الموقع‬ (Name): ‫تم الفحص‬
‫بواسطة‬:
Signature:‫التوقيع‬
Condition Presence
Day & Location Suitability
Condition of of Condition
IS THE EXCAVATION SAFE
Time ‫اليوم‬ of of Access of
of Ground Shoring if Ground Barriers ‫هل الحفرة آمنة‬
‫و الوقت‬ Excavation / Egress
Required Water
‫حالة‬ ‫مالءمة‬
‫وجود المياه‬ ‫حالة‬
‫موقع الحفرة‬ ‫حالة األرض‬ ‫الدعمات‬ ‫المداخل‬ YES NO
‫الجوفية‬ ‫الحواجز‬
‫إذا لزم‬ ‫والمخارج‬
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
AM
IF AN EXCAVATION IS UNSAFE IT MUST BE IMMEDIATELY VACATED AND MADE SAFE BEFORE RE-ENTRY
‫يجب إخالء الحفرة غير األمنة حتى يتم تصحيح الوضع غير األمن‬
Excavations must have been inspected by a competent person- at the start of the shift
of which the work is to be carried out- after any event likely to affect the strength or
stability of the excavation- after any material falls unintentionally or is dislodged.
‫يجب فحص الحفرة بواسطة الشخص المختص بالحفر بداية كل وردية‬

FORKLIFT CHECKLIST
Date Modified:
FORKLIFT CHECKLIST ‫قائمة فحص الرافعة الشوكية‬

PROJECT: ‫المشروع‬ Year: ‫سنة‬
Frequency: ‫معدل تكرار الفحص‬ Daily. ‫يومي‬
Driver's Name: ‫اسم سائق‬
Vehicle ID.: ‫رقم الرافعة‬
‫الرافعة‬
CONDITION OF EQUIPMENT ‫حالة المعدات‬
DATE ‫التاريخ‬ DATE ‫التاريخ‬ DATE ‫التاريخ‬ DATE ‫التاريخ‬ DATE ‫التاريخ‬ DATE ‫التاريخ‬
Forks ‫الشوكتين‬
Carriage ‫الحامل‬
Load Back Rest ‫الواقي الخلفي‬
‫للحمل‬
Mast Channels ‫قنوات الصاري‬
Rollers, Chain Wheels
‫البكرات‬, ‫عجالت السلسلة‬
Mounting Brackets / Bushes
‫قوسي اإلسناد \ بطانة معدنية‬
Tilt Cylinders / Brackets
‫إسطوانات الميالن و األقواس‬
Hydraulic cylinders/ Valves
‫االسطوانات الهيدروليكية و صمامات‬
Hoses & Piping ‫خراطيم وأنابيب‬
Attachment ‫المرفقات‬
OPERATION OF EQUIPMENT ‫معدات التشغيل‬

Mass. (Up / Down)
)‫أسفل‬/‫الرافغة (أعلى‬
Hydraulic Valves
‫الصمامات الهيدرولكية‬
Safety Stops / Devices
‫التوقف الوقائى‬
Lift / Tilt Cylinders
‫الرافعة \ إسطوانات الميالن‬
Attachment
‫المرفقات‬
Hour Meter / Gauges
‫المقاييس‬
LOUD INDICATORS ‫مؤشرات الحمل‬
Load Chart / Plate
‫لوحة أو رسم بياني للحمل‬
Load test
‫إختبار الحمل‬
Inspector Name & Signature /‫اسم‬

‫وتوقيع القائم بالفحص‬:

FORKLIFT CHECKLIST
Date Modified:
Eq. Name : ‫اسم المعدة‬ Forklift – ‫الرافعة الشوكية‬

Manufacture Company:‫الشركة المصنعة‬ Date of inspection : ‫تاريخ الفحص‬
No. (Tuv) ‫رقم الـ‬ Expiry Date : )TUV(‫تاريخ إنتهاء ال‬
Operator Tuv :‫) للمشغل‬Tuv(‫رقم الـ‬ Expiry TUV: ‫) للمشغل‬TUV(‫تاريخ انتهاء الـ‬
11 3 Comments 1
No Yes
2 / ‫مالحظات‬ Front & Back ‫اإلضاءة األمامية والخلفية‬

Comments Lights 2
No Yes
Revolve Light / ‫إضاءة المخاطر‬
Comments 3
No Yes
Reverse Alarm / ‫إنذار الرجوع للخلف‬
Comments 4
10 No Yes
Comments 5
No Yes
Comments 6
5 No Yes
/ ‫مالحظات‬ Lift/Tilt Cylinder ‫ اإلمالة‬/ ‫إسطوانة الرفع‬
Comments / 7
No Yes
Comments 8
No Yes
Forks / ‫الشوكتان‬
Comments 9
8 1
6 No Yes
/ ‫مالحظات‬ ‫بطانة معدنية‬/‫قوسي اإلسناد‬
Comments Load Backrest 10
No Yes
Mast / ‫الصاري‬
Comments 11
No Yes
Comments 12
No Yes
Load Chart / ‫الرسم البياني للحمل‬
Comments 13
No Yes
................................................................................................................................................................................................................... : Comment / ‫مالحظات حول الرافعة‬
............................................................................................................................................................................................................................................................................................................................



WELFARE CHECKLIST
Date Modified:
WELFARE CHECKLIST - Weekly ‫قائمة الفحص األسبوعي للمرافق والخدمات‬

Site: ‫الموقع‬
Welfare Facilities Checklist ‫قائمة فحص المرافق والخدمات‬ Yes No N/A

‫غير مطلوب‬
Adequate numbers of Toilets are readily accessible?

‫عدد دورات المياة مناسب و صالحة اإلستخدام؟‬
Sanitary
Conveniences These facilities are adequately ventilated and lit?
‫المرافق مزودة بالتهوية و اإلضاءة؟‬
Is there a system in place for keeping these facilities clean
‫دورات المياة‬ and in good condition?
‫هل يوجد نظام للمحافظة على نظافتها وأن تبقى سليمة‬
Do we have suitable washing facilities, including showers if
required and are they readily accessible? ‫هل تتوفر مرافق مناسبة‬
‫ تتضمن دش إذا تطلب و يمكن الوصول اليه بسهوله؟‬,‫لإلستحمام‬
Washing Are they in the immediate vicinity of every sanitary
Facilities convenience or changing area?
‫هل المرافق بالقرب من دورات المياة و غرف تغير المالبس؟‬
Are they supplied with clean running water?
‫هل المياة المستخدمة نظيفة وصالحة لإلستخدام؟‬
Adequately stocked with soap or other suitable means of
cleaning provided?
‫هل يتوفر الصابون او اي مستحضرات للنظافة؟‬
‫ مرافق اإلستحمام‬Are towels or other suitable means of drying provided?
‫هل تتوفر مناشف او ما شابه؟‬
Is the facility sufficiently ventilated and lit?
‫المرافق مزودة بالتهوية و اإلضاءة؟‬
and in good condition?
‫هل يوجد نظام للمحافظة على نظافتها وأن تبقى سليمة؟‬
Is the facility adequate for washing hands, forearms and the
face? ‫هل مغاسل االيدي و الوجة متوفره و مناسبه‬
Is there an adequate supply of wholesome drinking water
Drinking
and is it readily accessible and suitable placed?
Water
‫هل المياه الصالحة للشرب كافية و صحية و في متناول الجميع وفي مكان مناسب؟‬
Does an appropriate sign stating it if fit for consumption i.e.
green and white sign stating drinking water?
‫مياة الشرب‬ ‫هل توجد عالمات تبين حالة المياة (صالحة للشرب ام ال)؟‬
Are cups or other drinking vessels provided?
‫هل تم توفير كاسات بالستيكيه للشرب؟‬
Do they hold the correct certification, i.e. certified cook,
client approval,
Canteen
‫هل عمال المطعم يحملون شهادات صحية؟‬
Areas
Are these facilities equipped with fire extinguishers /
blankets?
‫هل تتوفر طفايات و بطانيات لمكافحة الحريق؟‬
‫منطقة المطاعم‬ and in good condition?
Are rest rooms or rest areas available and easily accessible?
‫هل غرف االستراحة او مناطق االستراحة متوفرة و سهلة الوصول اليها؟‬
Facilities for Are these facilities non-smoking?

Rest ‫؟‬ ‫هل تم منع التدخين بها‬
Are they equipped with an adequate number of seats for
persons at work likely to use them at any one time?
‫هل تتوفر بها كراسي كافية للعمال؟‬
and in good condition?

‫االستراحات‬ Are these facilities equipped with fire extinguishers?
‫هل تتوفر طفايات حريق؟‬
Are they located away from the work areas?
‫هل موقعها بعيدا عن موقع العمل؟‬
Checked By : ‫تم الفحص‬
Position : ‫الوظيفة‬ Date: ‫التاريخ‬
‫بواسطة‬

FABRICATED FRAME SCAFFOLDS INSPECTION

CHECKLIST
Date Modified:
FABRICATED FRAME SCAFFOLDS INSPECTION CHECKLIST ‫قائمة فحص للسقاالت الجاهزة‬
ITEM PARTICULARS OK NOT OK N/A ‫غير مطلوب‬ DEFICIENCY

Are frames secured by braces which
secure the vertical members

laterally? ‫هل اإلطارات مدعمة بمقصات لتثبيت‬
‫األجزاء األفقية و الرأسية؟‬
Do the braces automatically square
and align the frames? ‫هل المقصات تحافظ‬
‫على اإلتزان بما يالئم اإلطارات‬
Are all brace connections secured?
‫هل تركيب المقصات مؤمن ببنز االمان‬
Fabricated
frame Are frames joined together by
scaffolds coupling pins or equivalent means?
‫هل اإلطارات مرتبطة مع بعضها بمسامير ام بشي‬
‫اخر‬
Where uplift may occur are the
frames locked together?
‫هل تم ربط اإلطارات ببعضها لمنع إنفصال اإلطار‬
‫عن اإلطار الذي تحته؟‬
‫السقاالت‬
‫الجاهزة‬ Has the use of side brackets and their
impact on the overall scaffold been
fully evaluated?
‫عند استخدام مقصات عمل خارجية هل تم حساب‬
‫تأثيرها على السقالة‬
Have scaffolds over 125 feet in
height been constructed and loaded
according to design of a registered
professional engineer?
‫ قدم‬125 ‫هل السقاالت التي يزيد ارتفاعها عن‬
‫انشأت و حملت بما يتناسب مع تصميمها المعد من‬
‫قبل الشخص المختص‬
Prepared By: ‫إعداد‬ Reviewed By: ‫مراجعة‬

ORAL SCAFFOLDING INSPECTION CHECKLIST

Date Modified:
ORAL SCAFFOLDING INSPECTION CHECKLIST 1 ‫قائمة التفتيش العامه على السقالة‬
Inspection Date: ‫تاريخ الفحص‬
Project Name: ‫المشروع‬

Not N/A ‫غير‬
ITEM ‫العنصر‬ PARTICULARS OK
DEFICIENCY
OK ‫مطلوب‬
Has the scaffold been constructed to maintain a
safety factor of 4 to 1 4 ‫تم بناء السقالة للحفاظ على عامل السالمة‬
1 ‫الى‬
Has the scaffold been designed by a qualified

person? ‫هل تم تركيب السقالة بواسطة شخص متخصص‬
Has the scaffold platform been fully planked

with less than 1" between planks
1 ‫هل منصة السقالة آمنة والفراغ بين اخشاب منصة العمل اقل من‬
‫بوصة‬
The gap between the last plank and the uprights

less than 9 1/2 inches
‫ بوصة‬9.5 ‫هل المسافة بين آخر خشبة و العمود اقل من‬
Are all platforms at least 18 inches wide?

General ‫ بوصة‬18 ‫هل كل منصات العمل عرضها ال يقل عن‬
Requireme Are platforms that are less than 18 inches
nts ‫متطلبات‬ protected by guardrail systems or will all
‫عامة‬ employees have personal fall arrest systems?
‫ بوصة بها وسائل منع‬18 ‫هل المنصات التى يقل عرضها عن‬
( ‫السقوط ( هاندريل – حزام امان‬
Are open sides of scaffold less than 14 inches
from the face of the work?
‫ بوصة عن واجهة العمل‬14 ‫هل تبعد السقالة اقل من‬
Where open sides of scaffolds are more 14
inches will fall protection systems be used by all
employees? ‫ بوصة‬14 ‫هل لو تبعد السقالة عن المبنى اكثر من‬
‫هل يتوفر نظام حماية لكل العاملين على السقالة‬
For scaffolds that will be used for lathing and
plastering is the platform less than 18 inches
from the face of the work? ‫هل السقاالت المستخدمة في‬
‫(الدهانات ) هل تبعد عن واجهة الخراطة او اعمال البناء محارة‬
‫ بوصة‬18 ‫العمل بمسافة اقل من‬

Are all platform units cleated, restrained by
hooks or equivalent means, or extending over
the center line of their supports by at least 6
inches? – ‫تم تثبيت منصة العمل ( مشقبيات‬
‫ بوصة عن‬6 ‫خطافات – ام مدعمة من اسفل و تبرز بما ال يقل عن‬
‫الدعامة‬
Are platforms of 10 feet or less extending over
their end supports no more than 12 inches? ‫هل‬
‫قدم او اقل تبرز فوق الدعامة‬10 ‫منصة العمل التى طولها‬
‫ بوصة؟‬12 ‫ما اليزيد عن‬
Where platforms of 10 feet or less extend more than
12 inches have guardrails been installed to block
access to the overhang? ‫ قدم‬10 ‫هل منصة العمل التى طولها‬
General ‫ بوصة بها وسيلة حماية لمنع الوصول للبروز ؟؟‬12 ‫او اقل ولها بروز‬
Requireme
Are platforms of 10 feet or more extending over their
nts ‫متطلبات‬ end supports no more than 18 inches? ‫هل منصة العمل‬
‫عامة‬ ‫ بوصة فوق الدعامات‬18 ‫ قدم بها بروز ال يزيد عن‬10 ‫التى تزيد عن‬
‫؟؟‬
Where platforms of 10 feet or more extend more

than 18 inches have guardrails been installed to
block access to the overhang? ‫هل منصة العمل التى تزيد عن‬
‫ بوصة فوق الدعامات بها وسيلة حماية‬18 ‫ قدم بها بروز يزيد عن‬10
‫لمنع الوصول الى البروز‬
Are abutted planks resting on separate support

surfaces? )‫هل االلواح الخارجة مدعمة بدعامات منفصلة ( حماالت‬
Where planks are overlapped are they lapped over
the supports? ‫تداخل االلواح الخشبية بمنصة العمل يكون فوق‬
‫دعامة‬
Are planks overlapped at least 12 inches, nailed
together or otherwise secured? ‫هل الواح الخشب تتداخل بما‬
‫ ومربطة معا‬،‫بوصة‬12 ‫بمسامير او بطريقة اخرى آمنة ؟ اليقل عن‬
Are planks that rest on the bearer at other than a 90
degree angle laid first? ( ‫هل االلواح الموضوعة على الحوامل‬
‫ وضعت اوال ؟؟‬90 ‫الشياالت ) الموضوعة بدرجة‬
Are the top and bottom surfaces of the plank visible
and free from paint and other opaque finishes? ‫هل اعلى‬
‫االلواح و اسفلها واضح جيدا و خالى من مواد الطالء و التشطيبات‬
If scaffold components of different manufacturers are
used, do they fit together without force and has a
competent person determined that they are safe for
use? ‫هل توجد اجزاء في السقالة من شركات مختلفة ؟؟ ولو وجدت هل‬
‫تم تركيبها بالقوة ؟؟ و هل تم تركيبها بواسطة شخص متخصص يضمن‬
‫استخدامها بامان؟؟‬
Has the use of dissimilar metals (if any) been
evaluated by a competent person? ‫هل استخدام المعادن‬
‫المختلفة (إن وجدت) تم تقييمها من قبل شخص مختص ؟؟‬
Reviewed By:
Prepared By: ‫إعداد‬
‫مراجعة‬

N/A
Not
ITEM ‫العنصر‬ PARTICULARS OK ‫غير‬ DEFICIENCY
OK ‫مطلوب‬
Has the tie been installed at a horizontal
member that supports the inner and outer legs?
‫هل تمت عملية الربط االفقي التى تدعم االرجل الداخلية و‬
‫الخارجية‬
Has the first vertical tie been installed at a
height less than 4 times the minimum base
dimension? ‫هل أول مستوى لربط السقالة رأسيا عند أربع‬

‫اضعاف عرض قاعدتها؟‬
Have vertical ties been repeated every 20 feet
or less for scaffolds that are 3 feet or less in
width? ‫ قدم او اقل للسقاالت التى‬20 ‫هل تم الربط عموديا كل‬
‫ قدم او اقل‬3 ‫عرضها‬
Have vertical ties been repeated every 26 feet
or less for scaffolds wider than 3 feet? ‫هل تم الربط‬
‫ قدم؟‬3 ‫ قدم او اقل للسقاالت الي عرضها اكبر من‬26 ‫عموديا كل‬
Is the vertical distance from the top tie to the

Criteria For top of the scaffold less than the 4 to 1 minimum
Supported base dimension? ‫المسافة العمودية بين اخر ربط الى اخر‬
‫ من عرض القاعدة‬1 ‫ الى‬4 ‫نقطة في السقالة اقل من‬
Scaffolds
‫معايير الدعم‬ Are ties installed at each end of the scaffold and
‫للسقاالت‬ at horizontal distances not to exceed 30 feet?
‫هل الربط موجود عن كل اطراف السقالة و بصورة افقية بما ال‬
‫ قدم؟؟‬30 ‫يتجاوز‬
Where eccentric loads are imposed have ties
been installed to counteract these loads? ‫هل تم‬
‫عمل ربط لمواجهة االحمال المتغيرة‬
Are scaffolds erected on adequate firm

footings? ‫هل تم تركيب ارجل كافية‬
Are footings capable of supporting 4 times the
intended load without settling?
‫هل االرجل تتحمل اربع اضعاف الوزن المتوقع بدون مشاكل‬
Is the use of unstable objects prohibited for
footings? ‫هل يتم تثبيت االرجل علي اشياء غير ثابتة‬
Is scaffold plumb and braced to prevent
swaying or displacement? ‫هل السقالة متزنة ومستوية بما‬
‫ال يمنع ميالنها‬
Reviewed By:
‫مراجعة‬

Inspection Date: ‫تاريخ‬
‫الفحص‬
ITEM ‫العنصر‬ PARTICULARS OK DEFICIENCY
OK ‫مطلوب‬
Has safe access been provided for all

scaffold platforms that are more than
2 feet above or below the point of
access? ‫هل تم‬
2 ‫تامين مدخل آمن لكل منصات العمل بما يعادل‬
‫قدم اعلى او اسفل نقطة الدخول؟‬
Have cross braces been prohibited as

a means of access?
‫هل يمنع استخدام المقصات كطريقة للوصول‬
‫لمنصة العمل؟‬
Access ‫ وسائل‬Are ladders positioned so as not to
‫الوصول‬ tip the scaffold? ‫هل الساللم مركبة بطريقة‬
‫امنة للوصول للسقالة‬
Is the bottom rung less than 24

inches above the supporting surface?
‫ بوصة فوق‬24 ‫هل اول درجة ارتفاعها اقل من‬
‫السطح االرض اوخالفه‬
Are rest platforms installed every 35

feet vertically? ‫هل تم إنشاء منصة للراحة‬
‫ قدم رأسي‬35 ‫(بسطة) كل‬

ORAL SCAFFOLDING INSPECTION CHECKLIST

Date Modified:
Scaffolding work permit ‫تصريح عمل السقاالت‬

Zone ‫منطقة‬ Date ‫التاريخ‬ Scaffolding No‫رقم السقالة‬ Time ‫الوقت‬
Start Finish
Sign Sign
Job Description:
Erection‫تركيب‬ Modification‫تعديل‬ Dismantling‫تفكيك‬ Work over scaffolding‫أعمال اخرى‬
Checked by
Item ‫البند‬
Yes ‫نعم‬ No ‫ال‬ N/A‫غير مطلوب‬ Comment ‫تعليق‬
Vest ‫سترة‬
Foot protection
Required PPE
‫حماية القدم‬
Hand protection ‫حماية اليد‬
Head protection ‫حماية الرأس‬
Hearing protection ‫حماية االذن‬
Fall body harness ‫حزام السالمة‬
Certified as pear drawing ‫معتمد طبقا للرسم‬
Base plate ‫قاعدة اللوحة‬
Posts (standards) ‫األعمدة‬
Bearers ‫الحوامل االفقيه‬
Runners ‫القضبان االفقية‬
Base lift ‫ارتفاع العارضه الطويله عن القاعدة‬
Required in Scaffolding
Wood scaffold plank ‫الواح السقالة الخشبيه‬

Braces ‫دعامات‬
Top rail ‫الحاجز العلوي‬
Mid rail ‫الحاجز االوسط‬
Toe board ‫االلواح الطرفية الواقية‬
Staircase ‫السلم‬
Tool Box ‫اجتماع السالمة قبل العمل‬
Competent workers ‫عمال مختصين‬
Life line ‫حبل النجاة‬
Safe access ‫ممرات امنة‬
Light ‫االضاءه‬
Housekeeping ‫النظافة‬
:‫اإلصابات نهاية التصريح‬
................................ ‫عدد‬ ‫ال يوجد‬ ‫يوجد‬
Contd…..
‫شرح قواعد السالمة الخاصة بالعمل‬
‫التوقيع‬ ID‫رقم الهوية‬ Name ‫اإلسم‬ ‫التوقيع‬ ID‫رقم الهوية‬ Name ‫اإلسم‬
24 1
25 2
26 3
27 4
28 5
29 6
30 7
31 8
32 9
33 10
34 11
35 12
36 13
37 14
38 15
39 16
40 17
41 18
42 19
43 20
44 21
45 22
46 23
48 24
50 25
‫مسؤول السالمة‬ ‫المراقب‬ ‫المهندس المسؤول‬

:‫اإلسم‬ :‫اإلسم‬ :‫اإلسم‬
:‫التوقيع‬ :‫التوقيع‬ :‫التوقيع‬
:‫اإلصابات نهاية التصريح‬

................................ ‫عدد‬ ‫ال يوجد‬ ‫يوجد‬

MOBILE SCAFFOLDS INSPECTION CHECKLIST

Date Modified:
MOBILE SCAFFOLDS INSPECTION CHECKLIST ‫قائمة فحص السقاالت المتحركة‬

ITEM PARTICULARS OK DEFICIENCY
OK ‫مطلوب‬
Are frames secured by braces which secure the

vertical members laterally?
‫هل االطارات مدعمة بالمقصات لتثبيت األجزاء األفقية و الرأسية‬
Do the braces automatically square and align the
frames? ‫هل الدعمات‬
‫أتوماتيكيه للمحافظة على االتزان واالستواء المالئم لإلطارات؟‬
Are all brace connections secured?
)‫هل تم تامين تركيب الدعامات ( بنز‬
Do scaffolds constructed of tube and clamp meets
CHEC-SBG-
the requirements of that type of scaffold? HSSE--28
‫هل السقاالت األنبوبية تحقق متطلبات األوشا؟‬
Do scaffolds constructed of frame scaffolding meet
the requirements of that type of scaffold? CHEC-SBG-
‫هل السقاالت اإلطارية تحقق متطلبات األوشا؟‬ HSE-25
Are casters locked during use?.

‫هل تم تثبيت و اقفال العجالت أثناء اإلستخدام؟‬
MOBILE Is the manual force used to move the scaffold
SCAFFOLDS applied as close to the base as possible?
‫هل يتم تحريك السقالة بدفعها من المنطقة األقرب للقاعدة قدر اإلمكان؟‬
Are scaffolds stabilized to prevent tipping during

movement? ‫هل السقالة مستقرة بطريقة تمنع وقوعها اثناء‬
‫الحركة‬
Are casters pinned into the frames or adjustment
screws? ‫هل العجل‬
‫مثبت باالطار ( الشباك ) ام بالقاعدة المعدنية‬
OSHA 1926.452 (w) (6) does allow employees to
ride on rolling towers while the tower is being
moved under certain criteria. These criteria are
listed in section (w) (6). However, the Scaffold
Training Institute does not recommend this practice.
If rolling scaffolds are being moved with employees
on board, are all the criteria of 452(W) met?
‫يمنع بتاتا تحريك السقالة اثناء وجود العمال عليها حسب تعليمات االوشا‬
‫و معهد تدريب السقاالت اال بضوابط معينة‬

TUBE & COUPLER SCAFFOLDS INSPECTION

CHECKLIST
Date Modified:
TUBE AND COUPLER SCAFFOLDS INSPECTION CHECKLIST 1

Inspection Date: ‫تاريخ‬
‫الفحص‬

OK ‫مطلوب‬
Is "X" bracing installed on the ends of the

scaffold and every third set of posts horizontally
and every fourth runner vertical?
‫هل المقصات تم تركيبها بطريقة صحيحة مرتبطة بالقوائم و‬
‫ عوارض راسيا‬4 ‫اعمدة افقيا وكل‬3 ‫العوارض كل‬
Are ties installed at the bearer level?
‫هل تم عمل ربط في مستوى العوارض‬
Is longitudinal bracing installed at a 45 degree
angle on both faces of the scaffold?
‫ درجة في كال وجهى‬45 ‫هل الدعامات الجانبية تم تركيبها بزاوية‬
‫السقالة‬
Does the longitudinal bracing extend from the
first (left hand) post to the extreme top of the
scaffold?
TUBE AND ‫بالكامل من االعلي الي المقصات الطولية تشمل االطار االول‬
COUPLER ‫االسفل‬
SCAFFOLDS If the scaffold is longer than five posts, is a new
line of bracing begun at every fifth post?
‫ قوائم ؟؟ هل تم تركيب دعامات كل‬5 ‫هل السقالة اطول من مقدار‬
‫خمس قوائم‬
Is bracing installed as close as is possible to the
node point?
‫هل تم تركيب المقصات في اقرب نقطة من نقطة التقاء القوائم و‬
)‫العوارض ( العقدة‬
Are the bearers attached to both posts and does
the inboard coupler rest on the runner coupler?
‫هل العوارض القصيرة مرتبطة بالقوائم و هل هي مرتكزة على‬
‫العوارض الطويلة‬
Do the ends of the bearer tube have full contact
within the clamp?
‫هل نهاية العوارض الطولية متصلة كليا بالكلبسات‬
Prepared By: Reviewed By:
‫إعداد‬ ‫مراجعة‬
Position: ‫الوظيفة‬ ` Position: ‫الوظيفة‬

TUBE AND COUPLER SCAFFOLDS INSPECTION CHECKLIST 2

OK ‫مطلوب‬
If outside runners are left out, are there mid rails

and guardrails above and below the point where
the runner would have been?
‫في حالة عدم وجود العوارض العرضية هل يوجد نظام جاردريل‬
‫بديل‬
Are runners interlocked and coupled to each
post?
‫هل العوارض العرضية متشابكة و مرتبطة بالقوائم‬

Are the bottom runners as close to the base as
possible?
‫هل العوارض العرضية السفلية قريبة بقدر االمكان من القاعدة‬
Do light and medium-duty scaffolds have posts,
runners, bearers and braces of 2" O.D. steel
tubing?
‫هل السقاالت الخفيفة و المتوسطة تملك أعمدة أفقية و رأسية و جانبية‬
‫ بوصة؟‬2 ‫و دعمات من األنابيب الصلبة قطرها الخارجي‬
TUBE AND
COUPLER Are posts on light-duty scaffolds spaced no more
SCAFFOLDS than 4' apart by 10' along the length of the
scaffold?
‫ قدم‬4 ‫هل األعمدة الرأسية للسقاالت الخفيفة التزيد المسافة بينها عن‬
‫ قدم علي كامل طول السقالة؟‬10 ‫و مقسم الجزاء بطول‬
Are posts on medium-duty scaffolds spaced no
more than 4' apart by 7' along the length of the
scaffold?
4 ‫هل األعمدة الرأسية للسقاالت المتوسطة التزيد المسافة بينها عن‬
‫ قدم علي كامل طول السقالة؟‬7 ‫قدم و مقسم الجزاء بطول‬
Is the maximum vertical runner spacing of 6'6"?
‫ قدم؟‬6.6 ‫هل أقصى مسافة بين األعمدة األفقية هي‬
If the maximum number of planked levels,
working levels, or height exceeds those shown in
table b are drawings done by a registered
professional engineer?
‫اذا زاد عددالمنصات المستخدمة أو يتخطى االرتفاع الوارد بجدول‬
‫التصميم فيتم فحص السقالة من قبل متخصص محترف‬
Reviewed By:
‫مراجعة‬

LIFT PLAN FOR CRANES

Date Modified:
Lift Plan for Cranes ‫خطة الرفع‬

1)Contractor / ‫المقاول‬ J.O. No.:‫رقم العمل‬
2)Crane Inspection Sticker valid: Yes 
No Date of expiry:
‫الصقة تاريخ فحص الرافعة‬  ‫تاريخ انتهاء الفحص‬
No Description of load
3) Operator certified: ‫المشغل المعتمد‬ Yes 
 ‫وصف الحمل‬
5)Type of crane to be used: Stowed Erected N/A

_______ ‫منصوب‬ ‫غير موجود‬
(lbs/kgs)
‫نوع الرافعة المستخدمة‬ ‫محفوظ‬
Boom length (total) ‫ متر‬/‫طول البوم قدم‬ ______ ft./m Jib:‫الجيب‬    ___
Jib length‫طول الجيب‬ ______ ft./m Extension‫االمتداد‬    ___

Comments by Operator
Hook block Main:
   ___
‫الهوك الرئيسى‬
Aux. Boom Head ___
‫الهوك المساعد‬
  
Headache Ball:    ___

Slings, Shackles, etc.
‫االدوات المساعده الحبال‬
___
  
‫والسالسل‬
Others:‫اشياء اخرى‬    ___
Total (Gross Load Weight):‫وزن الحمل االجمالى‬
Effective weight of jib
6)Weight of load ‫وزن الحمل‬ (lbs/kgs) _____________ lbs/kgs (see jib chart)
‫الوزن الفعلى للجيب‬
Effective weight of jib headache ball Weight of load block
(lbs/kgs) _____________ lbs/kgs
‫الوزن الفعلى للجيب‬ ‫وزن الهوك‬
Weight of hoist rope below boom tip Weight of spreader bar
‫وزن حبل الرفع تحت البوم‬ (lbs/kgs) _____________ lbs/kgs
‫وزن دعمة الرفع‬
Weight of other rigging
(lbs/kgs)
(‫وزن المعدات المساعدة ( الحبال والسالسل‬
Total load weight ‫وزن الحمل الكلى‬ (lbs/kgs)
9. Operating radius
7)Hoisting clearance ‫مسافة التحميل‬ 8) Lift quadrant zone ‫الرفع منطقة‬
‫نصف قطر التشغيل‬
ft./m ft./m
10) Crane capacity at operating
_________ (Note: Do not make lift if total load is greater than crane capacity shown in Item10)
radius ‫سعة الرافعة عند نصف قطر التشغيل‬
11) Crane capacity for jib configuration: 12) Ground and site condition
_________ _______
‫سعة الرفعة عند تكوين الجيب‬ ‫شروط الموقع واالرض‬
13)Wind speed: ‫سرعة الرياح‬ (Maximum 20 mph)
14)Work permit enquired: Yes
No 
‫تصريح العمل المطلوب‬  Type
15) Load moment indicator: Yes ‫نوع‬
No 
‫مبين عزوم الحمل‬ 
Sketch and supplementary information for crane lift is required to be attached to this plan. (Note: The sketch of the crane should
include the following rigging information: size of each component; safe working load (SWL) capacity; length of slings; type of
component; component diameter; weight of component and sling angles) . ‫المعلومات التكميليه والرسومات البيانيه الخاصة بالرافعة يتم ارفاقها مع هذة‬
‫مالحظة (الرسم البيانى للرافعة يجب ان يشمل معلومات االدوات المساعدة من حيث نوعها وحجمها والحمل االمن لها وكذلك طولها ونصف قطرها‬.‫الخطة‬.
‫أعد بواسطة‬Prepared by
Date:‫التاريخ‬: Reviewed by (Crane Date:‫التاريخ‬:
(Rigger1) : Name & Signature
Operator) Name &
Approved Name & Signature Signature : ‫المراجعة‬:
Date:‫التاريخ‬: Date:‫التاريخ‬:
:‫الموافقة‬
EQUIPMENT CHECKLIST
Date Modified:
Equipment Checklist ‫قائمة فحص األدوات‬

AREA / FACILITY CHECKED
DATE ‫ التاريخ‬:
‫ فحص المناطق والمرافق‬:
PROJECT ‫ مشروع‬:
SAFETY DEVICES
POWER ENERATION ‫مولد الطاقة‬ A U/A A U/A
‫وسائل السالمة‬
Condition ‫الحالة العامة‬ ELCB’S / RCD’S ‫القواطع‬
Housekeeping ‫النظافة‬ Isolation Points ‫نقاط العزل‬
Outlets ‫مخارج التيار الكهربائي‬ Panels Locked ‫إغالق اللوحات‬
ELECTRICAL HAND TOOLS

CABLES ‫الكابالت‬ A U/A A U/A
‫األدوات الكهربائية اليدوية‬
Connections ‫التوصيالت‬ Condition ‫الحالة العامة‬
Termination’s ‫النهايات‬ Double Insulated ‫عزل مضاعف‬
Sockets and Fittings ‫مخارج الكهرباء‬

Condition ‫الحالة العامة‬
‫مناسبه‬
Capacity & Ratings
‫القدرة &التصنيفات‬
Routings / Cable Management
‫المسارات وإدارة الكابالت‬
EARTHING ‫التوصيل باألرضي‬ A U/A FITTINGS ‫التجهيزات‬ A U/A
No exposed cables / wires

Distribution Boards ‫لوحات التوزيع‬
‫التوجد كابالت او اسالك مكشوفة‬
Cabins/Offices ‫المكاتب والكابينات‬ Condition ‫الحالة العامة‬
Transformers / Generators
Non Domestic ‫ليست صناعة العمال‬
‫المحوالت و مولدات الطاقة‬
A = Acceptable ‫مقبول‬ U/A = Unacceptable ‫غير مقبول‬
Comments ‫ مالحظات‬:

WASTE LOG CHECKLIST

Date Modified:
WASTE LOG ‫سجل النفايات‬

(Non-hazardous Waste) ‫مخصص نفايات ليست خطيرة‬
Area / ‫ المنطقة‬:
Waste In-Charge Tel. No :
‫هاتف المسئول عن النفايات‬:
Contractor Tel. No / ‫هاتف المقاول‬:

Origin of Waste ‫مصدر النفايات‬:
Qty. of
Name of Waste Date Time Disposal
Waste Unit Vehicle No Manifest Remarks
Stream ‫أنواع‬ Dispatched Dispatched Point No. ‫مالحظات‬
(No./Kg.) ‫تاريخ اإلرسال‬ ‫وقت اإلرسال‬
‫رقم المركبة‬
‫نقطة التخلص منها‬
‫النفايات‬
‫كمية النفايات‬
AQUEOUS WASTE
‫معالجة النفايات المائية‬
Sewage Effluent -
Untreated ‫نفايات الصرف‬
‫الصحي غير المعالجة‬
Sewage Sludge
‫رواسب مياة الصرف الصحي‬
SOLID WASTE ‫النفايات‬

‫الصلبة‬
Domestic Refuse
‫المخلفات المنزليه‬
Industrial Refuse
‫المخلفات الصناعية‬
GASEOUS WASTE
‫النفايات الغازية‬
Refrigerant ‫المبردات‬
Fire Fighting Agent

‫أدوات مكافحة الحريق‬
FUGITIVE GASES
‫الغازات المتبخرة‬
Any other Waste

‫نفايات اخرى‬
`
Signature‫التوقيع‬:
Name ‫االسم‬:
Designation ‫الوظيفة‬:

CONFINED SPACE ENTRY PERMIT

Date Modified:
CONFINED SPACE ENTRY PERMIT/ ‫تصريح عمل لألماكن المغلقة‬

Section 1 Performing Authority: ‫مسئول العمل‬
Initiator’s Name Supervisor’s Name
‫اسم طالب التصريح‬ ‫اسم المشرف‬
................................................................................................................
Work Description:
................................................................................................................
‫وصف العمل‬
................................................................................................................
Department
‫القسم‬
Location Equipment No. &
‫الموقع‬ Description
No. of Workforce: ‫رقم المعدات & وصفها‬
‫عدد العمال المصرح لهم بالدخول‬
Task duration
Date ‫التاريخ‬
:‫مدة البقاء بالمكان الضيق‬
Safety Requirements Precautions
Section 2
‫إحتياطات السالمة المطلوبة‬
Safety Precautions & Equipment Requirements (please check box if yes)
)‫إحتياطات وادوات السالمة المطلوبة( اشر على المطلوب‬
 Personnel Protective Equipment (PPE)  Emergency Rescue Equipment
‫مهمات السالمة الشخصية‬ ‫ادوات اإلنقاذ في حاالت الطوارى‬
 Full Body Harness  Stand-By Watchman

‫حزام األمان‬ ‫شخص للمراقبة والمتابعة‬
 All energy sources are closed & released  Non-Sparking / Special Tools
‫تم إغالق جميع مصادر الطاقة والتخلص من الطاقة المتبقية‬ ‫ادوات خاصة‬
 Means of Access  Means of Ventilation

‫المداخل والمخارج‬ ‫وسائل التهوية‬
 Lighting / Illumination  Gas Monitor

‫اإلضاءة‬ ‫مراقبة نسب الغازات‬
 barricade& Secure work Area

‫تأمين منطقة العمل‬
Additional Safety Precautions ‫احتياطات سالمة إضافية‬
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

‫جدول متابعة قياس الغازات داخل األماكن المغلقة‬
‫التحقق رقم ‪6‬‬ ‫التحقق رقم ‪5‬‬ ‫التحقق رقم ‪4‬‬ ‫التحقق رقم ‪3‬‬ ‫التحقق رقم ‪2‬‬ ‫التحقق رقم ‪1‬‬
‫الحدود المسموحة‬ ‫الغاز المقاس‬
‫الوقت‬ ‫القياس‬ ‫الوقت‬ ‫القياس‬ ‫الوقت‬ ‫القياس‬ ‫الوقت‬ ‫القياس‬ ‫الوقت‬ ‫القياس‬ ‫الوقت‬ ‫القياس‬
‫من ‪%23.5:%19.5‬‬ ‫أكسجين‬

‫‪ 10 PPm‬ال تزيد عن‬ ‫‪H2s‬‬
‫ال تزيد عن ‪%10‬‬ ‫غازات قابلة لالشتعال‬
‫‪ 60 PPm‬ال تزيد عن‬ ‫أول أكسيد الكربون‬
‫‪Section 3‬‬ ‫‪Declaration‬‬ ‫التعهد‬

‫‪I have read, understood and shall comply with the work instructions and safety requirements‬‬
‫أتعهد انني قرأت وفهمت الية العمل ومتطلبات السالمة الواجب توفيرها‬
‫‪Supervisor Signature‬‬ ‫توقيع المشرف‬
‫‪Engineer’s Signature‬‬ ‫توقيع المهندس‬

‫‪Section 4‬‬ ‫‪Approval‬‬ ‫التصديق‬
‫‪Permit is Valid from ...to‬‬
‫تاريخ ووقت صالحية التصريح من – إلى‬
‫‪safety supervisor/ Engineer‬‬
‫توقيع مسؤول السالمة‬
‫‪Section 5‬‬ ‫‪Work Completion‬‬ ‫إنتهاء العمل‬
‫‪The Location / Equipment has been restored to normal and safe conditions at :‬‬ ‫تم تسليم الموقع والمعدات بحالة جيدة وسليمة‬
‫‪Time‬‬ ‫الوقت‬ ‫‪Date‬‬ ‫التاريخ‬

‫‪safety supervisor/ Engineer‬‬ ‫‪Performer Signature‬‬
‫توقيع مسؤول السالمة‬ ‫توقيع مسئول العمل‬
‫‪Section 6‬‬ ‫‪Work Acceptance‬‬ ‫إستالم العمل‬
‫‪The Location / Equipment has been received safe for normal operation‬‬ ‫تم تسليم الموقع والمعدات بحالة جيدة وسليمة‬
‫‪Engineer’s Name‬‬ ‫اسم المهندس‬ ‫‪Signature‬‬ ‫التوقيع‬
‫‪Time‬‬ ‫الوقت‬ ‫‪Date‬‬ ‫التاريخ‬

‫‪Section 7‬‬ ‫‪Usage of Permit on Other Days‬‬ ‫لتمديد مدة التصريح‬
‫‪Date‬‬ ‫التاريخ‬
‫‪From Time‬‬ ‫من الساعة‬
‫‪To Time‬‬ ‫الى الساعة‬

‫‪Signature‬‬ ‫التوقيع‬
‫أسماء العاملين المصرح لهم بالدخول ‪-:‬‬

‫خروج‬ ‫دخول‬ ‫خروج‬ ‫دخول‬ ‫الرقم الوظيفي‬ ‫االســـــم‬ ‫م‬
‫‪1‬‬
‫‪2‬‬
‫‪3‬‬
‫‪4‬‬
‫‪5‬‬
‫‪6‬‬
‫‪7‬‬
‫‪8‬‬
‫‪9‬‬
‫‪10‬‬
‫يلغى التصريح فى الحاالت التالية ‪-:‬‬
‫عند وجود اعمال وأنشطة جديدة ‪.‬‬ ‫‪.1‬‬
‫عند وجود أشخاص غير مدرجين بالتصريح ‪.‬‬ ‫‪.2‬‬
‫الخروج من المكان وعدم العودة للعمل لمدة تزيد عن ‪ 30‬دقيقة ‪.‬‬ ‫‪.3‬‬
‫استمرار العمل للوردية التالية ‪.‬‬ ‫‪.4‬‬
‫تغيير ظروف العمل بالموقع ‪.‬‬ ‫‪.5‬‬
‫يتم إرفاق تقييم المخاطر الخاص بالعمل وكذلك الـ ‪ Tool Box Talk‬وأي مستندات أخري مطلوبة تتعلق بسالمة العاملين‬

EXCAVATION WORK PERMIT

Date Modified:
EXCAVATION WORK PERMIT ‫تصريح عمل للحفر‬

Section 1 Performing Authority ‫مسئول العمل‬
Initiator’s Name ‫اسم طالب التصريح‬ Co. / Dept. ‫ القسم‬/‫الشركة‬
Function ‫الوظيفة‬
Job Performance Name:
Exact Location Area: ‫المنطة المحدد‬
Depth: Width: Length: ‫الطول‬:‫ العرض‬:‫العمق‬
Drawing/sketch attached ‫تم ارفاق رسم توضيحي‬ Yes  No 

Section 2: Verification ‫التحقق‬
This is to certify that the area/location of excavations is clear from underground services and thus
work can be carried out safely: ‫موقع الحفر خالي من الخدمات االرضية وآمن‬
Elect./instr. Section name: Date

Signature:
‫اسم المسئول عن العزل الكهربائي‬ :
Mech./Civil section name: Date

Signature:
‫اسم المسئول عن الخدمات المدنية والميكانيكية‬ :
Telecom section name: Date

Signature:
‫اسم المسئول عن اإلتصاالت‬ :
Area Authority (HSE. Eng. /Sup.)
Section 3:
‫مسئول المنطقة او مدير السالمة‬
Safety Precautions & Requirements (Yes  No ) ‫)إحتياطات وادوات السالمة المطلوبة( اشر على المطلوب‬
 Safe means of access/ingress ‫مداخل ومخارج آمنة‬  Road Closure / ‫إغالق الطرق‬
 Internal support / ‫دعم داخلي‬  Hand tools / ‫األدوات اليدوية‬
 Barriers / ‫حواجز‬  Power tools / ‫األدوات الكهربائية‬
 Warning signs (reflective) ‫عالمات تحذيرية مضيئة‬  Standby watch / ‫شخص للمراقبة‬
 Flashing lights / ‫إضاءات فالش‬  Gas freeing / ‫خالية من الغازات‬
 Personal Protective Equipment / ‫مهمات السالمة‬
‫الشخصية‬
Additional Safety Precautions:
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………….……………………………………………………
………………………………………………………………………………………………………………………………………………………

Section 4: Declaration ‫التعهد‬
I have read, understood and shall comply with the work instructions and safety requirements
‫أتعهد انني قرأت وفهمت الية العمل ومتطلبات السالمة الواجب توفيرها‬
Initiator’s Name Performer Signature
‫اسم طالب التصريح‬ ‫توقيع مسئول العمل‬
Section 5: Approval ‫التصديق‬
Permit is Valid from ‫تاريخ صالحية التصريح من‬ Hrs. to Hrs. Date/ ‫التاريخ‬
Signature
Area Authority (HSE. MGR.) Name:
‫التوقيع‬
Section 6: Work Completion: ‫إنتهاء العمل‬
The Location / Equipment has been restored to normal and safe conditions at : Date:
‫التاريخ تم تسليم الموقع والمعدات بحالة جيدة وسليمة‬
Initiator Signature: Performer Signature

‫التوقيع‬ ‫توقيع مسئول العمل‬
Section 7: Work Acceptance: ‫إستالم العمل‬
The Location / Equipment has been received safe for normal operation Hrs. Date:
‫التاريخ تم تسليم الموقع والمعدات بحالة جيدة وسليمة‬
Area Authority (HSE) Sign: Time:
‫الوقت مسئول السالمة المنطقة‬
Section 8: Extension: ‫تمديد التصريح‬
Date
‫التاريخ‬
From Hrs.
‫من الساعة‬
To Hrs.
‫إلي الساعة‬
Inspector Name & Signature ‫اسم وتوقيع‬

‫مفتش السالمة‬
HSE Name & Signature. ‫توقيع مسئول‬

‫السالمة‬
Attachment files like tool box, JHA, Risk Assessment: ‫ارفاق ملفات تدعم التصريح مثل تحليل المخاطر الخ‬

HOT & COLD WORK PERMIT CHECKLIST

Date Modified:
Permit NO ‫ رقم التصريح‬: WORK PERMIT : HOT COLD

Permit Duration ‫مدة‬ Days/hours Start Date ‫تاريخ البداية‬ Valid Up to ‫تاريخ النهاية‬
‫التصريح‬
Receiver’s Name/ID ‫اسم المستلم‬/‫رقم وظيفي‬ Company ‫الشركة‬ Department ‫القسم‬
Phone No ‫رقم الجوال‬

Section 1: location, work description, safe system requirements ‫متطلبات السالمة‬، ‫ وصف العمل‬،‫الموقع‬
Work description ‫وصف العمل‬:
Location ‫الموقع‬: Zone ‫المنطقة‬: level‫الدور‬: Axis ‫المحاور‬:

Attachments ‫( المرفقات‬please check box if yes) ( ‫)اشر على المطلوب‬
Risk Assessment ‫تقييم المخاطر‬ TBT Attendance Sheet ‫كشف حضور محاضرة التوعية‬
3rd Party Certificates ‫شهادات فحص الطرف الثالث‬
Method Of Statement ‫خطوات تنفيذ العمل‬
Pre-Operation Checklist ‫قائمة الفحص قبل التشغيل‬
Task Location Layout ‫موقع العمل على الخريطة‬ Inspection Checklists ‫ قوائم الفحص‬/No‫عددها‬:
PPE & other equipment (please check box if yes) ‫)اشر على المطلوب (معدات ومهمات السالمة‬
Full Body Harness ‫حزام السالمة‬ Fire Extinguisher ‫( طفاية حريق‬DCP □CO2 □ Sign & Barricading ‫حواجز وعالمات‬
‫تحذير‬
AFFF Foam □ )
Equipment lockout tag out ‫عزل مصادر الطاقة‬ Fire blanket ‫بطانية حريق‬ Chemical Suit ‫معطف للمواد الكيميائية‬
Excavation support ‫تدعيم الحفر‬ safety shoe ‫حذاء سالمة‬ Hard Hat ‫خوذة‬
Face &/or Eye Protection ‫و العين‬/‫واقي الوجه أو‬ Gloves Respirators ‫اجهزة‬
Welding Goggles‫نظارة لحام‬ □Face Shields‫واقي وجه‬ ‫(قفازات‬Cotton‫قماش‬ □leather‫□جلد‬rubber□ ‫(تنفس‬dust □‫اتربة‬/gas□‫)غازات‬
□safety glasses
‫□نظارة‬ ‫)مطاط‬
Additional Attachments/safety Precautions ‫احتياطات سالمة إضافية‬/ ‫مرفقات‬
Section 2: Signature& Approvals: A joint inspection has been conducted? Yes □ No□ if no why? ‫هل تم عمل فحص مشترك للموقع؟ نعم ال إذا ال لماذا‬
Site responsible 1st day date 2nd day date 3rd day date 4th day date 5th day date 6th day date
‫مسئولي الموقع‬ ‫تاريخ اليوم االول‬ ‫تاريخ اليوم الثاني‬ ‫تاريخ اليوم الثالث‬ ‫تاريخ اليوم الرابع‬ ‫تاريخ اليوم الخامس‬ ‫تاريخ اليوم السادس‬
Shift ‫الوردية‬
Execution responsible
‫مسئول التنفيذ‬
Phone N ‫رقم الجوال‬
Day
Safety responsible
Afternoon
Safety responsible
Night
Safety responsible
Issuer name ‫اسم مصدر التصريح‬ Id ‫رقم وظيفي‬ signature ‫التوقيع‬ Date/shift ‫التاريخ والوردية‬
Section 3 work completion/closure ‫انتهاء العمل وإغالق التصريح‬

The Location / Equipment has been restored to normal and safe conditions ‫تم تسليم الموقع والمعدات بحالة جيدة وسليمة‬
Safety Responsible / Id ‫رقم وظيفي‬ Phone No ‫رقم الجوال‬ signature ‫التوقيع‬ Date/shift ‫التاريخ والوردية‬
‫اسم مسئول السالمة‬
Execution Responsible/ Id ‫رقم وظيفي‬ Phone No ‫رقم الجوال‬ signature ‫التوقيع‬ Date/shift ‫التاريخ والوردية‬
‫اسم مسئول التنفيذ‬
Permit Status ‫حالة التصريح‬ Opened ‫مفتوح‬ Closed ‫مغلق‬ Suspended ‫معلق‬ Canceled ‫ملغى‬

‫‪Electrical Welding Work Permit‬‬ ‫تصريح العمل ألعمال اللحام بالكهرباء‬
‫مسئول العمل‬ ‫القسم األول‬

‫إسم المشرف‬ ‫إسم طالب التصريح‬
‫ماكينة اللحام ‪TUV‬‬ ‫القسم‬
‫رقم ماكينة اللحام‬ ‫الموقع‬
‫وصف العمل‬ ‫عدد العمال‬
‫مسئول المنطقة‬ ‫القسم الثاني‬

‫إحتياطات وأدوات السالمة المطلوبة‬
‫األماكن المعلقة‬ ‫أدوات خاصة‬
‫األماكن المغلقة‬ ‫حواجز وعالمات تحذير‬
‫العمل تحت ظروف غير مألوفة‬ ‫معدات مكافحة الحريق‬
‫التهوية‬ ‫التأريض‬
‫التأكد من عدم وجود مواد قابلة لإلشتعال مكان اللحام‬ ‫اإلضاءة‬
‫مالبس خاصة باللحام‬ ‫أجهزة التنفس‬
‫واقي الوجه‬ ‫واقي اليد‬
‫مالحظة‬ ‫ال‬ ‫نعم‬ ‫اللحام والقطع‬
‫العامل أو المشغل مؤهل‬
‫معدات التشغيل بحالة جيدة‬
‫كابالت المعدة بحالة جيدة‬
‫توفير طفاية حريق مناسبة‬
‫التفتيش عن مخاطر الحريق في مكان اللحام قبل البدء‬
‫حواجز وعالمات تحذير‬
‫رجل المتابعة‬
‫التأكد من خلو المكان من أي مصدر يسبب إشتعال بعد إنتهاء العمل‬
‫التعهد‬ ‫القسم الثالث‬

‫أتعهد أنا الموقع أدناه أنني قرأت وفهمت آلية العمل ومتطلبات السالمة الواجب توافرها للعمل‬
‫توقيعه‬ ‫إسم المشرف‬
‫توقيعه‬ ‫إسم المهندس‬
‫إنتهاء العمل‬ ‫القسم الرابع‬

‫تم تسليم الموقع بحالة جيدة‬
‫التاريخ‬ ‫الوقت‬
‫مشرف السالمة‬ ‫مسئول العمل‬
‫أرفق ملف يدعم التصاريح مثل تقييم المخاطر ‪...‬إلخ‬

Gas Welding Permit Work ‫تصريح العمل ألعمال اللحام بالغاز‬
Section 1 ‫مسئول العمل‬labor official ‫م‬20 / / ‫التاريخ‬
‫اسم المشرف‬
‫ اسم طالب التصريح‬Name Supervisor
name
‫ الموضوع‬Subject ‫رقم التصريح‬
Permit no
‫رقم المعدات ووصفها‬
‫ القسم‬Department
No of equipment
‫ الموقع‬location ‫معدات وأدوات العمال‬
‫عدد العمال‬ ‫وصف العمل‬
Number of workers Job description
Section 2 Zone official ‫مسئول المنطقة‬
(Click on the desired) safety precaution and tools required ‫أشر على المطلوب احتياطات وادوات السالمة‬
‫ األماكن المعلقة‬Outstanding places ‫ أدوات خاصة‬Special Tools

‫ وجود فالش باك في بداية ونهاية الخرطوم‬The presences of ‫تأمين المعدات ووضع عالمات‬Ensuring The Equipment And Tagging
flashback at the beginning and end of the tube ‫إخراج الضغط المتبقي‬Take out the remaining pressure
‫ الحفر‬Drilling ‫حواجز وعالمات تحذير‬barriers and warning signs
‫ العمل في ظروف غير مألوفة‬Work under unusual ‫معدات مكافحة الحريق‬firefighting equipment
circumstance
Safety Precaution required ‫احتياطات السالمة المطلوبة‬
(Click on the desired) safety precaution and tools required ‫أشر على المطلوب احتياطات وادوات السالمة‬
‫ وسائل التهوية‬Liquid ventilation ‫ أدوات اإلنقاذ في حاالت الطوارئ‬Emergency rescue tools
‫ اإلضاءة‬Lighting ‫ شخص للمراقبة والمتابعة‬Someone to watch and follow
‫تخفيف الضغط والتخلص من الغازات المشتعلة‬ ‫ تأمين المعدات ووضع عالمات إليقاف العمل‬Someone to watch and follow
Reduce pressure and get rid of burning gases
additional Safety Precaution ‫احتياطات سالمة إضافية‬

‫خوذة‬helmet Safety belt‫حزام السالمة‬
‫ كمامة غبار‬muzzle mask One-time use cleaner‫منظف لالستعمال مرة واحدة‬
‫ حزام سالمة‬Safety Belt ‫ شخص للمتابعة‬Someone to follow
‫ قفازات الحماية من المواد الكيميائية‬Chemical protection ‫ نظارات‬GLASSES
gloves
‫ واقي األذن‬Ear guard ‫ أجهزة تنفس‬Respirator devices
‫واقي الوجه‬Face protector Chemical Cleaner‫منظف للمواد الكيميائية‬
‫ أجهزة تنفس صناعي‬Respirator devices ‫ قفازات قطنية‬Cotton Gloves
welding and cutting ‫اللحام والقطع‬ Yes No comments
The worker or operator is qualified‫العامل أو المشغل مؤهل‬
‫ تأمين معدات السالمة الشخصية المناسبة‬Ensuring appropriate personal safety
equipment
‫ معدات التشغيل بحالة جيدة‬Operating equipment in good condition
‫ خراطيم الغاز محمية وفي حالة جيدة‬Gas hoses are protected and in good condition
‫ تقييد خراطيم الغاز بسالسل وفي وضع رأسي صحيح‬Gas hoses are chained and in an
upright position
Provide a suitable fire extinguisher‫توفير طفاية حريق مناسبة‬
‫ التفيش على مخاطر الحريق في مواقع اللحام‬Inspection of fire hazards at welding
sites
‫ حواجز وعالمات تحذير‬Warning barriers
‫ استخدام علبة األسطوانات‬Use the disc tray
‫ شخص للمتابعة‬Someone to follow
Section 3 ‫ التعهد‬pledge
I pledge that I have read and understand the working mechanism and safety requirements that must be met ‫أتعهد بأنني قرأت وفهمت آلية العمل‬
‫ومتطلبات السالمة الواجب توفرها‬
‫ توقيع المشرف‬supervisor
‫اسم المشرف‬supervisor Name
Signature
‫ اسم المهندس‬Engineer Name ‫ توقيع المهندس‬Engineer Signature

Section 4 ‫ انتهاء العمل‬The Work Is Finished
The equipment is delivered and the location is in good condition ‫تم تسليم المعدات والموقع بحالة جيدة‬
‫التاريخ‬ ‫الوقت‬
‫توقيع المشرف‬ ‫توقيع مسئول‬

‫العمل‬
Attach files supporting permits such as risk analysis etc. ‫إرفاق ملفات تدعم التصاريح مثل تحليل المخاطر الخ‬

WORKING HEIGHT / WORK PERMIT
Date Modified:
Section: 1 Details of Work ‫تفاصيل العمل‬

Permit NO: ‫رقم التصريح‬ Location of Work ‫مكــــان العمل‬
Date / ‫التاريخ‬
Work Requested by ‫طالب العمل‬ Company / ‫الشركة‬
Contact Number ‫رقم التواصل‬
Description of Work ‫وصف العمل‬

Approximate Height Work Will Be Carried Out……………. Meters High ‫ م‬....................‫تقريبا يتم العمل على ارتفاع‬
Site supervisor ‫المشرف على العمل‬ Name :‫االسم‬ ID. .‫الرقم الوظيفي‬ Department ‫القسم‬
Section: 2 – Hazards- ‫المخاطر‬

 Falling ‫السقوط‬  Risk of Falling Persons ‫مخاطر سقوط أشخاص‬ 
 High Wind speed ‫سرعة رياح عالية‬  Overhead Electric Cables ‫ كابالت كهربائية علوية‬
 Unguarded ‫ غير محمية‬  Unsecured Ladders ‫ اللم غير مؤ ّمنة‬
 Lack of Space ‫مسافات بينية خطرة‬  Uneven Floor Surface ‫ أرضيات غير مستوية‬
 Manual Handling of Loads ‫ تداول أحمال يدويا‬  Fragile Roof ‫ رخوة‬/ ‫ أرضية هشة‬
Other Hazard not Identified Above ‫مخاطر أخرى‬
Section: 3 - Means of Access ‫وسائل الوصول‬

Ladders: ‫الساللم‬ Yes No Comment
Ladders in Good Cond ‫هل الساللم بحالة جيدة ؟‬
Are the side rails intact without any cracks, bends, or breaks?
‫ اإلنحناءات و الكسور؟‬,‫هل هل الحواجز الجانبية سليمة و خالية من التشققات‬ -
Barrier at Base of Ladders and Warning Sign? ‫هل تم تأمين المنطقة بواسطة الحواجز وعالمات التحذير؟‬
Is laddering suitable for the work being carried out? ‫هل الساللم مناسبة لطبيعة العمل المنفذ ؟‬
Access Scaffolding:‫ممرات السقاالت‬ Yes No Comment

Toe Board in Place? ‫هل توجد حواجز منع سقوط األشياء؟‬
Barrier and Warning Sign in Place? ‫هل تم وضع حواجز وعالمات تحذيرية‬
Hand Rails in Place? ‫هل يوجد حاجز حماية من السقوط؟‬
Working Height:‫العمل على االرتفاعات‬ Yes No Comment

All safety harnesses & other falling protection equipment are inspected
- ‫هل تم فحص حزام األمان وكل معدات الحماية من السقوط األخري‬
All hand/power tools are safe and secured from falling

‫هل كل العدد واألدوات اليدوية أو التي تعمل بالطاقة آمنة و مؤمنة من السقوط‬
All employees who are included in this permit are competent and without any health troubles to do
their tasks safely
‫هل كل العاملين المدرجين بهذا التصريح من ذوي الكفاءة وال يعانون من مشاكل صحية تعيقهم عن العمل‬
All Environmental conditions are suitable and safe to work

‫هل كل الظروف البيئية مناسبة وآمنة للعمل‬
There is no Electrical Hazards in the work area

‫ال يوجد مخاطر للكهرباء في منطقة العمل ؟‬

‫أسماء المصرح لهم بالعمل ‪Names of authorized persons /‬‬
‫الرقم الوظيفي ‪ID/‬‬ ‫المهنة‪Profession/‬‬ ‫االســــــــــــــــــــم ‪Name /‬‬ ‫‪/ N‬م‬
‫‪Section: 4 - Under taking by WP Inspector‬‬ ‫(تتم بواسطة ُمصدر التصريح)‬

‫‪I declared that the above has been made known to the competent person in-charge of the work‬‬
‫‪and consider the above mentioned are to be safe of the competent person to commence work‬‬
‫قد قمت بإعالن كل ما سبق للقائمين بتنفيذ العمل ويعتبر كل ما هو أعاله واضح لألشخاص األكفاء لبدء العمل‬
‫التوقيع‬ ‫التاريخ‬ ‫االسم‬ ‫الوظيفة‬
‫فني السالمة والصحة المهنية‬
‫مسؤول السالمة والصحة المهنية‬
‫‪Section: 5 - Under taking by WP Receiver‬‬ ‫(تتم بواسطة المصدر لة التصريح)‬

‫اقرار وتعهد باالتزام بكافة التعليمات الموضحة من قبل السالمة والصحة المهنية وتحمل المسؤولية الكاملة عند حدوث اية تجاوز‬
‫التوقيع‬ ‫التاريخ‬ ‫االسم‬ ‫الوظيفة‬
‫الفني المصرح له‬
‫مهندس الموقع‬
‫مدير المنطقة‬

‫‪ELECTRICAL PERMIT TO WORK‬‬
‫‪Document No: SBG-HSE – 036‬‬ ‫‪Revision: 8‬‬
‫الموقع‪................................................................ : Location /‬‬ ‫التاريخ ‪Date ............................................................................................................................. ........................ :‬‬
‫رقم المكتب‪/‬منطقة العمل ‪.......................................................‬‬ ‫الوقت من ‪ / from.....................................‬إلى ‪Time to ...........................................................‬‬

‫اسم المسؤول عن المكتب‪/‬منطقة العمل‪......................................‬‬
‫القسم ‪...............................................................................‬‬ ‫وصف نوع العمل المطلوب ( صيانة مكاتب – صيانة مولد – صيانة لوحة كهربائية – إلخ)‬
‫رقم التواصل‪......................................................................‬‬ ‫‪............................................................................................................................................‬‬
‫التوقيع ‪............................................................................‬‬ ‫‪............................................................................................................................................‬‬
‫الوصــف ‪Description /‬‬

‫إجراءات السالمة قبل العمل ‪Pre Job Safety Task /‬‬ ‫‪Yes‬‬ ‫‪No‬‬
‫هل كل الكابالت معزولة ومؤمنة ؟‬

‫في حالة وجود أي عارض من اآلتي يتم إيقاف تحرير التصريح‪:‬‬
‫? ‪All cables are secured and Insolated safely‬‬
‫ال‬ ‫نعم‬ ‫هل يوجد توصيل أرضي‪:‬‬
‫? ‪Is there GFCI‬‬ ‫هل يوجد قاطع تسريب للتيار ؟‬
‫ال‬ ‫نعم‬ ‫عدم وجود مياه على أرضية العمل‪:‬‬
‫ال‬ ‫نعم‬ ‫في حالة وجود سقاالت هل هي آمنة‪:‬‬
‫هل لوحة الكهرباء بحالة جيدة ؟ ?‪Is the electrical panel in a good condition‬‬
‫التحكم في الخطر ‪Measures /‬‬
‫المخاطر ‪Hazards /‬‬ ‫? ‪No unauthorized persons‬‬ ‫هل جميع األشخاص العاملين مؤهلين ؟‬
‫‪Control‬‬
‫هل يوجد بموقع العمل أي مخلفات أو ظروف غير آمنة محيطة ؟‬
‫? ‪Is there any poor houskeeping or unsafe condition‬‬
‫صيانة‬ ‫تشغيل‬ ‫نوع تصريح العمل‪:‬‬ ‫‪‬‬ ‫? ‪Is the elecrtical current insolated or shut down‬‬ ‫هل تم فصل التيار الكهربي ؟‬
‫تيار مستمر‬ ‫تيار مغلق‬ ‫نوع التيار‪:‬‬ ‫‪‬‬ ‫?‪Is there adequate lighting in work location‬‬ ‫هل اإلضائة جيدة بمكان العمل ؟‬
‫هل تم إستخدام مهمات السالمة الشخصية الخاصة بالكهرباء ؟‬
‫نوع األدوات المستخدمة ‪...‬عددها وحالتها ( آمنة‪ /‬غير آمنة )‬
‫‪All workers wear suitable PPE‬‬
‫‪ ................... 1.‬العدد ‪ .......‬الحالة ‪..............‬‬ ‫هل يتم استخدام بطاقات الغلق و األقفال ؟‬
‫‪ ................... 2.‬العدد ‪ .......‬الحالة ‪..............‬‬ ‫? ‪Is Lockout / Tag out in use effectively‬‬
‫‪ ................... 3.‬العدد ‪ .......‬الحالة ‪..............‬‬ ‫هل توجد طفاية حريق مناسبة و صالحة ؟‬
‫?‪Is there a vaid and suitable fire exitigusher‬‬
‫‪ ................... 4.‬العدد ‪ .......‬الحالة ‪..............‬‬
‫هل العاملين بدراية علي بالمخاطر المرتبطة بالعمل وكيفية التعامل اآلمن معها؟‬
‫‪ ................... 5.‬العدد ‪ ........‬الحالة ‪..............‬‬ ‫?‪Is the operator or maintainance aware about all hazards related to work‬‬
‫أنا ‪ /‬نحن استلمت تصريح العمل وتم فحص اجراءات السالمة قبل العمل وعلى دراية بمتطلبات السالمة فيه والخاصة بالعمل الذي أقوم به ‪.‬‬
‫وسوف أقوم ‪ /‬نقوم باتباع وتنفيذ تعليمات السالمة ‪ .‬وسنقوم بإيقاف العمل إذا ما كان الوضع غير آمن وسنخطر المسؤول عن ذلك‬
‫تم اإلنتهاء من العمل بشكل آمن‬
‫‪Commitment: I Know all hazards and measure control related to my work ,‬‬
‫‪and I will follow Safety insturctions and stop the work in case of hazard.‬‬
‫اسم و توقيع مسؤول السالمة‬
‫توقيع المشغل ‪ /‬القائم بالصيانة ‪........................................................................................‬‬
‫‪.....................................................................................‬‬
‫توقيع مهندس الكهرباء المسؤول ‪.......................................................................................‬‬
‫توقيع مسؤول السالمة على سالمة منطقة العمل أثناء عمل التصريح ‪...............................................‬‬
‫عدد ‪................................................‬‬ ‫ال يوجد‬ ‫يوجد‬ ‫اإلصابات نهاية التصريح‬
‫‪Causes of permit's cancellation:‬‬ ‫في حالة إلغاء التصريح يتم ذكر األسباب‪:‬‬
‫‪..........................................................................................................................................‬‬
‫اسم وتوقيع مسؤول المكتب ‪ /‬منطقة العمل‬ ‫في حالة إيقاف العمل يرجي تعبئة الجدول التالي‬
‫المدير التنفيذي‬ ‫توقيع الكهربائي‬ ‫توقيع مسؤول السالمة‬
‫‪.....................................................................................‬‬
‫‪..............................‬‬ ‫‪..............................‬‬ ‫‪..............................‬‬
‫وقت إيقاف العمل‬ ‫تاريخ إيقاف العمل‬
‫‪..............................‬‬ ‫‪..............................‬‬

‫أسماء العاملين المصرح لهم بالعمل ‪- :‬‬
‫اتعهد بانه تم تقديم شرح توضيحي لطريقة العمل االمنة حسب متتطلبات السالمة والصحة المهنية والبيئة‬
‫وعلية فاننى ملزم بتتطبيق جميع متتطلبات العمل االمنه واتحمل كافة المسؤولية فى حالة المخالفة‬
‫التوقيع‬ ‫الرقم الوظيفي‬ ‫االســــــــــــــــــــــــــم‬ ‫م‬
‫‪1‬‬
‫‪2‬‬
‫‪3‬‬
‫‪4‬‬
‫‪5‬‬
‫‪6‬‬
‫‪7‬‬
‫‪8‬‬
‫‪9‬‬
‫‪10‬‬
‫‪11‬‬
‫‪12‬‬
‫‪13‬‬
‫‪14‬‬
‫‪15‬‬
‫‪16‬‬
‫‪17‬‬
‫‪18‬‬
‫‪19‬‬
‫‪20‬‬
‫‪21‬‬
‫‪22‬‬
‫‪23‬‬
‫‪24‬‬
‫‪25‬‬
‫توقيع المشرف ‪ /‬المهندس المسؤول عن العمل‬ ‫توقيع مشرف ‪ /‬مهندس السالمة‬

PERMIT TO WORK EXTENDED HOURS & NIGHT WORK

Date Modified:
PERMIT TO WORK EXTENDED HOURS AND NIGHT WORK

‫تصريح عمل لتمديد ساعات العمل و العمل في الورديات في الليل‬
Project: ‫المشروع‬
1. Permit No. ‫رقم التصريح‬ 2. Permit Validity ‫صالحية التصريح‬ From On Date
To On Date
3. Job Location ‫موقع العمل‬
4. Work Activity ‫النشاط‬

Number of
5. Number of Men on the Job Number of Foremen
Workers ‫عدد‬
‫عدد العمال‬ ‫عدد المشرف‬
‫العمال‬
6. Name of Permit Holder
‫اسم حامل التصريح‬
7. Name of Permit Authority
‫اسم مسئول التصاريح‬
8. Job Checklist, to be completed by the Permit Holder Tick the appropriate response:-
‫ضع عالمة على الخيار المناسب‬ Yes N/A
‫ يجب اكمالها بواسطة حامل التصريح‬,‫قائمة العمل‬
a) The Permit Holder shall remain at the work site throughout the Permit validity period
‫البد من تواجد حامل التصريح في الموقع حتى انتهاء صالحية التصريح‬
b) PPE will be provided and its use shall be enforced by the Permit Holder
‫يجب على حامل التصريح توفير واستخدام مهمات السالمة الشخصية‬
c) Adequate lighting has been provided at all work locations and access points
‫اإلضاءة جيدة في جميع مواقع العمل‬
d) Adequate means of access have been provided
‫المداخل والمخارج موفرة وبحالة جيدة‬
e) The Permit Holder shall notify the Duty HSE Supervisor of any accidents
‫يجب على حامل التصريح تنبيه مسئول السالمة في حالة وقوع حادث‬
f) The Duty HSE Supervisor shall notify the Client’s Duty Officer of any accidents
‫يجب على مسئول السالمة تنبيه المالك عند وقوع حادث‬
g) The Duty HSE Supervisor is equipped with a radio or mobile telephone
‫يمكن التواصل مع مسئول السالمة عن طريق الكول او الهاتف‬
h) The bus and driver will be located at the job location
‫الحافلة متواجده ومجهزة بالسائق في موقع العمل‬
i) Arrangements for late meals have been made
‫تم التعهد على توفير وجبات للعمال‬

9. Approval of Permit
‫التصديق على التصريح‬
The work covered by the Permit Signed Permit Holder ‫حامل التصريح‬
may commence.
‫ربما بداْ العمل الذي يغطى بواسطة التصريح‬ Signed Permit Authority ‫مسئول التصريح‬
10. Permit Closure
‫إنهاء التصريح‬
The work covered by this Permit was completed at On Date
‫تم اإلنتهاء من العمل المصرح له في‬
Permit Holder
The work site has been restored and the Signed ‫حامل التصريح‬
Permit is closed. ‫تم إغالق تصريح العمل‬ Signed Permit Authority
PERMIT MANAGEMENT / ‫إدارة التصاريح‬

1. This Permit is valid only when Sections 1 to 9 inclusive are complete.

‫ لكي يتفعل التصريح‬9 ‫ الى‬1 ‫يجب إكمال األجزاء من‬
2. The original Permit shall be displayed at the work place and shall at all times remain under the
responsibility of the Permit Holder.
‫يجب عرض التصريح في موقع العمل وتحت مسئولية حامل التصريح‬
3. A separate copy of the completed Permit at both the approval and closure stages shall be given to the Permit
Authority, the HSE Department and the Client.
‫توزيع صور من التصريح على مسئول التصاريح وقسم السالمة واالستشاري‬
4. This Permit shall be taken on a daily basis for extended hours working.
‫يصدر تصريح يومي في حالة تمديد ساعات العمل‬
5. This Permit shall be taken on a weekly basis for night shift working.
‫يصدر تصريح العمل اسبوعيا في حالة الورديات الليليه‬
6. The Permit Holder shall apply for a Permit to the HSE Officer by 15:00 hrs. On the applicable day.
15:00 ‫يتم طلب تصريح العمل من مكتب السالمة عند الساعة‬
7. Permit approval is to be completed by 1600hrs on the applicable day.

16:00‫يجب اكمال التصريح والتصديق عليه عند الساعة‬

RADIOGRAPHY PERMIT
Date Modified:
Section 1 Performing Authority ‫مسئول العمل‬

Initiator’s Name Radiographer Name
‫اسم طالب التصريح‬ ‫اسم فني األشعة‬
Title Company
‫الموضوع‬ ‫الشركة‬
Department Work Location
‫القسم‬ ‫موقع العمل‬
__________________________________________________________________________________________________________
Work Description __________________________________________________________________________________________________________
‫وصـف العـمــل‬
__________________________________________________________________________________________________________
Section 2 Radiation Source (Radiographer) )‫مصدر األشعة (فني األشعة‬
Radiation Source Activity Equipment Approval Measurement μ SV/H

‫األشعة‬ ‫المصدر‬ ‫النشاط‬ ‫تصديق على المعدات‬ ‫قياس مستوى اإلشعاع‬
Safety Requirements – please check boxes if yes

Section 3
‫متطلبات السالمة – الرجاء التأشير على المطلوب‬
Film Badge ‫بطاقة قياس اإلشعاع‬ Means of Communication ‫وسائل االتصال‬
Dosimeter ‫جهاز قياس اإلشعاع‬ Warning Signs ‫عالمات تحذير‬
Survey Meter (‫مقياس المسح اإلشعاعي (لتقدير كمية اإلشعاع‬ Personnel Clearance ‫إخالء المنطقة‬
Flashlight / Siren ‫ صفارة اإلنذار‬/ ‫مصباح يدوي‬ Barriers ‫حواجز‬
Additional Safety Precautions : ‫إحتياطات سالمة إضافية‬
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Section 4 Declaration ‫التعهد‬

I confirm that radiography work shall be conducted as per safety requirements and without any harm
to personnel outside the barricaded area
‫أؤكد أنه تم عمل مسح لإلشعاع تحقيقا ً لمتطلبات السالمة ودون أي ضرر لألشخاص خارج المنطقة المحصنة‬
Radiographer Name:
‫اسم فني األشعة‬
Radiographer Signature:
‫توقيع فني األشعة‬
Date: ‫التاريخ‬

Section 5 Approval ‫التصديق‬
Gas Safety
Gas Safety
Representative
Representative Name
Signature
‫اسم مسئول السالمة للغازات‬
‫توقيع مسئول السالمة للغازات‬
Permit is Valid from Permit is Valid to
‫التصريح صالح من تاريخ‬ ‫الــــى‬
Area Authority Name Signature

‫اسم مسئول المنطقة‬ ‫التوقيع‬
Section 6 Work Completion ‫إنتهاء العمل‬

The work has been completed and the radioactive source has been safely stored
‫تم االنتهاء من العمل وتم تخزين المصدر المشع بأمان‬
Radiograph Time ‫الوقت‬
Signature ‫التوقيع‬ Date ‫التاريخ‬
Section 7 Distribution ‫توزيع نسخ التصريح‬
Original ‫األصل‬ 1st Copy 1 ‫النسخة‬
2nd Copy 2 ‫النسخة‬ 3rd Copy 3 ‫النسخة‬

‫‪LIFTING / RIGGING OPERATION PERMIT - MC‬‬

‫ج‬
‫التاريخ ‪ Date ............................................................................................................ :‬الموقع‪.................................................... : Location /‬‬

‫نوع الرافعة ورقمها ‪Type& Number of Crane‬‬
‫الوقت من ‪ / from........................................‬إلى ‪Time to ..............................................‬‬
‫‪.............................................................................‬‬
‫إحداثيات المنطقة المنقول إليها‬ ‫إحداثيات المنطقة الموجود بها‬
‫نوع الحمولة ‪..............................................................................................................‬‬
‫‪..................................‬‬ ‫‪......................................‬‬
‫إجراءات السالمة قبل العمل ‪Pre Job Safety Task /‬‬ ‫‪Lifting work Permit Details‬‬ ‫بيانات تصريح الرفع‬
‫‪YES‬‬ ‫‪NO‬‬ ‫الوصــف ‪Description /‬‬
‫التحكم في الخطر ‪/‬‬
‫المخاطر ‪Hazards /‬‬ ‫هل الرافعة لها شهادة من طرف ثالث موجودة وسارية ؟‬
‫‪Measures Control‬‬
‫?‪Is The Crane Certified from 3rd party and the certificate is valid‬‬
‫هل توجد شهادة سارية من طرف ثالث لملحقات الرافعة ؟‬
‫? ‪Is there valid 3rd party certificate for lifting accessories‬‬
‫هل مشغل الرافعة حاصل على شهادة سارية من طرف ثالث ؟‬
‫?‪Is the operator certified by 3rd party and his certificate is valid‬‬
‫هل موجه الرافعة حاصل على شهادة سارية من طرف ثالث ومؤهل للقيام بعمله ؟‬
‫‪Is the rigger certified by 3rd party with valid certificate and he is‬‬
‫? ‪comptent to do this work‬‬
‫? ‪Is load radius indicator in good condition‬‬ ‫هل مؤشر التحميل يعمل بحالة جيدة ؟‬
‫?‪There is any problem in traffic management‬‬ ‫هل توجد مشكالت في حركة المرور ؟‬
‫ضع عالمة ( √) إذا كانت منطــقة العمل جاهــزة‬ ‫?‪Strong wind / rain condition‬‬ ‫هل يوجد رياح او امطار قوية ؟‬
‫‪Put ( √ )if the work area is ready and safe‬‬ ‫?‪Use proper tag line to control all loads‬‬ ‫استخدام حبال لتوجية الحمل؟‬
‫?‪Is Operators visibility clear‬‬ ‫هل منطقة العمل واضحة لمشغل الرافعة ؟‬
‫?‪Is there Adequate Illumination‬‬ ‫هل اإلضاءة جيدة ؟‬
‫? ‪Is load chart available and followed‬‬ ‫هل يوجد رسم بياني ألحمال الرافعة ؟‬
‫? ‪hydrolic oil leakage‬‬ ‫هل يوجد تسريب لزيت الهيدروليك ؟‬
‫? ‪Is the soil compacted and stable safely and outriggers are used correctly‬‬
‫هل األرضية مستوية وصلبة وتم استخدام الركائز بشكل صحيح ؟‬
‫هل تم عمل فحص الهوكات ‪ ،‬السالسل ‪ ،‬البكرات والذراعو مفتاح االيقاف المحدد والإلطارات‬
‫قبل اإلستخدام وأن جميعها بحالة جيدة ؟‬
‫‪Is The pre-use inspection has been for hooks,chains ,pullys ,limit swich‬‬
‫?‪and in good condition‬‬
‫خلف‬
‫هل منطقة العمل حول الرافعة المتحركة مؤمنة ؟‬
‫? ‪The work area around the mobile crane is secured and barricaded‬‬
‫وسائل االتصال بحالة جيدة؟ ?‪Communication devices and in good condition‬‬
‫عدد اإلصابات نهاية التصريح‪:‬‬ ‫هل تم معرفة وزن الحمل والتحقق من مالئمة وزن الحمل لقدرة الرافعة‬
‫عدد ‪................................‬‬ ‫ال يوجد‬ ‫يوجد‬ ‫‪Weight of the load to be lifted known‬‬
‫يجب االمتثال لكل ماورد في التصريح اثناء الرفع‬ ‫أنا ‪ /‬نحن استلمت تصريح العمل وتم فحص اجراءات السالمة قبل العمل وعلى دراية بمتطلبات السالالمة فياله والخاصالة بالعمالل‬
‫‪Work Shall carry out only after complying with this permit.‬‬ ‫الالالذي أقالالوم بالاله ‪ .‬وسالالوف أقالالوم ‪ /‬نقالالوم باتبالالاع وتنفيالالذ تعليمالالات السالالالمة ‪ .‬وسالالنقوم بإيقالالاف العمالالل إذا مالالا كالالان الوضالالع غيالالر آمالالن‬
‫في حالة مخالفة أي من البنود أعاله يتم إلغاء التصريح وال يتم التصريح بالعمل إال بعد تصحيح الوضع‬
‫وسنخطر المسؤول عن ذلك ‪Cometment: I Know all hazards and measure control related to my .‬‬
‫‪If any of safety instruction unfollowed, the permit will be canceled‬‬
‫‪-‬‬ ‫‪work , and I will follow safety insturctions and stop the work in case of hazard‬‬
‫توقيع مشغل الرافعة ‪...................................................................................... Operator /‬‬
‫في حال إنتهاء المدة المحددة للتصريح والمذكورة أعاله يعتبر التصريح الغي ‪.‬‬
‫توقيع موجه الرافعة ‪............................................................................ Rigger )1)/‬‬
‫يجب التأكد من توفير جميع متطلبات السالمة للمعدة والعاملين والمشغلين والموجهين الخاصين بعملية الرفع‬ ‫‪-‬‬
‫توقيع موجه الرافعة ‪.....................................................................................Rigger (2) /‬‬
‫توقيع مسؤول الرفع بالموقع (مهندس التنفيذ)‪Lifting Officer(Execution Engineer) :‬‬ ‫في حالة إلغاء التصريح وايقاف الرافعة يتم ذكر األسباب‪Causes of permit's cancellation :‬‬
‫‪.............................................................................................................................. .‬‬
‫‪...............................................................................‬‬
‫في حالة ايقاف الرافعة يرجى تعبئة الجدول التالي ‪- :‬‬
‫توقيع مسؤول السالمة‬ ‫‪Construction Manager‬‬ ‫‪Safety Manager‬‬ ‫‪Safety Engineer‬‬
‫‪......................................... .................................. ...............................‬‬
‫‪............................................................................‬‬ ‫وقت إيقاف الرافعة‬ ‫تاريخ اإليقاف‬
‫‪..............................‬‬ ‫‪..............................‬‬
‫*تم التأكد من توفير جميع المتطلبات الخاصة بعملية الرفع وعلى ذلك يتم تحميل مسؤول الرفع بالموقع (مهندس التنفيذ) كامل المسؤولية في حال اإلخالل بإشتراطات ومتطلبات أنظمة السالمة‬

‫‪LIFTING / RIGGING OPERATION PERMIT - MC‬‬

‫أسماء العاملين المصرح لهم بالعمل ‪:‬‬
‫اتعهد بانه تم تقديم شرح توضيحي لطريقة العمل االمنة حسب متتطلبات السالمة والصحة المهنية والبيئة وعلية فاننى ملزم بتتطبيق جميع متتطلبات العمل االمنه واتحمل كافة المسؤولية فى حالة المخالفة‬
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‫‪LIFTING / RIGGING OPERATION PERMIT - TC‬‬

‫الموقع‪............................................................ : Location /‬‬ ‫التاريخ ‪Date ........................................................................................................................... :‬‬

‫نوع الرافعة ورقمها ‪Type& Number of Crane‬‬ ‫الوقت من ‪ / from.......................................................‬إلى ‪Time ....................................................‬‬
‫‪.............................................................................‬‬ ‫‪to‬‬
‫إحداثيات المنطقة المنقول إليها‬ ‫إحداثيات المنطقة الموجود بها‬
‫نوع الحمولة ‪................................................................................................................................‬‬
‫‪.........................................‬‬ ‫‪.........................................‬‬
‫إجراءات السالمة قبل العمل ‪Pre Job Safety Task /‬‬ ‫بيانات تصريح الرفع‬
‫‪Lifting work Permit Details‬‬

‫‪YES‬‬ ‫‪NO‬‬ ‫الوصــف ‪Description /‬‬
‫‪Control‬‬
‫?‪Is The Crane Certified from 3rd party and the certificate is valid‬‬
‫‪Is the rigger certified by 3rd party with valid certificate and he is comptent to do‬‬
‫? ‪this work‬‬
‫? ‪Is load radius indicator in good condition‬‬ ‫هل مؤشر التحميل يعمل بحالة جيدة ؟‬
‫?‪There is any problem in traffic management‬‬ ‫هل توجد مشكالت في حركة المرور‬
‫ضع عالمة ( √) إذا كانت منطــقة العمل جاهــزة‬ ‫?‪No strong wind / rain condition‬‬ ‫اليوجد رياح او امطار قوية ؟‬
‫‪Put ( √ )if the work area is ready and safe‬‬
‫?‪Use proper tag line to control all loads‬‬ ‫استخدام حبال لتوجية الحمل؟‬
‫هل منطقة العمل حول الرافعة مؤمنة ؟‬
‫? ‪The work area around the mobile crane is secured and barricaded‬‬
‫?‪Communication devices and in good condition‬‬ ‫وسائل االتصال بحالة جيدة‬
‫?‪Load within SWL‬‬ ‫الحمولة في مدي الحمل اآلمن ؟‬
‫خلف‬ ‫‪Crane within safe working radius‬‬ ‫مجال عمل الرافعة خالى من العوائق‬
‫‪lifting radius security‬‬ ‫تأمين مسار الرفع‬

‫عدد اإلصابات نهاية التصريح‪:‬‬
‫عدد ‪..................................‬‬ ‫ال يوجد‬ ‫يوجد‬
‫أنا ‪ /‬نحن استلمت تصريح الع مل وتم فحص اجراءات السالمة قبل العمل وعلى درايالة بمتطلبالات السالالمة فياله والخاصالة بالعمالل‬
‫الذي أقوم به ‪ .‬وسوف أقوم ‪ /‬نقوم باتباع وتنفيذ تعليمات السالمة ‪ .‬وسنقوم بإيقاف العمل إذا ما كان الوضع غير آمن وسنخطر‬
‫يجب االمتثال لكل ماورد في التصريح اثناء الرفع‬ ‫المسؤول عن ذلك ‪Cometment: I Know all hazards and measure control related to my work , .‬‬
‫‪Work Shall carry out only after complying with this permit.‬‬ ‫‪and I will follow safety insturctions and stop the work in case of hazard‬‬
‫‪-‬‬ ‫توقيع مشغل الرافعة ‪...................................................................................... Operator /‬‬
‫توقيع موجه الرافعة ‪............................................................................ Rigger )1)/‬‬

‫توقيع موجه الرافعة ‪.....................................................................................Rigger (2) /‬‬
‫‪.............................................................................................................................. .‬‬
‫‪..............................................................................‬‬
‫توقيع مسؤول السالمة‬ ‫المدير التنفيذي‬ ‫توقيع مسئوول الرافعة‬ ‫توقيع مشرف السالمة‬
‫‪...........................................‬‬ ‫‪.........................................‬‬ ‫‪...............................‬‬

‫‪............................................................................‬‬
‫وقت إيقاف الرافعة‬ ‫تاريخ اإليقاف‬
‫‪............................................................‬‬ ‫‪............................................................‬‬
‫*تم التأكد من توفير جميع المتطل بات الخاصة بعملية الرفع وعلى ذلك يتم تحميل مسؤول الرفع بالموقع (مهندس التنفيذ) كامل المسؤولية في حال اإلخالل بإشتراطات ومتطلبات أنظمة السالمة‬

‫‪LIFTING / RIGGING OPERATION PERMIT - TC‬‬

‫)‪Document No: SBG-HSE – 039/02(a‬‬ ‫‪Revision: 8‬‬
‫أسماء العاملين المصرح لهم بالعمل ‪:‬‬

‫اتعهد بانه تم تقديم شرح توضيحي لطريقة العمل االمنة حسب متتطلبات السالمة والصحة المهنية والبيئة وعلية فاننى ملزم بتتطبيق جميع متتطلبات العمل االمنه واتحمل كافة المسؤولية فى حالة المخالفة‬
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‫‪LIFTING / RIGGING OPERATION PERMIT - CC‬‬

‫الموقع‪................................................................... : Location /‬‬ ‫التاريخ ‪Date .................................................................................................................. :‬‬
‫نوع الرافعة ورقمها ‪Type& Number of Crane‬‬ ‫الوقت من ‪ / from..........................................‬إلى ‪Time to ..................................................‬‬
‫‪...............................................................................................‬‬
‫إحداثيات المنطقة المنقول إليها‬ ‫إحداثيات المنطقة الموجود بها‬ ‫نوع الحمولة‬
‫‪.......................................‬‬ ‫‪.........................................‬‬ ‫‪.........................................................................................................................................‬‬
‫إجراءات السالمة قبل العمل ‪Pre Job Safety Task /‬‬ ‫‪Lifting work Permit Details‬‬ ‫بيانات تصريح الرفع‬
‫‪Yes‬‬ ‫‪No‬‬ ‫الوصــف ‪Description /‬‬
‫‪Control‬‬
‫?‪Is the Crane Certified from 3rd party and the certificate is valid‬‬
‫‪Is the rigger certified by 3rd party with valid certificate and he is‬‬
‫? ‪comptent to do this work‬‬
‫هل مؤشر التحميل يعمل بحالة جيدة ؟ ? ‪Is load radius indicator in good condition‬‬
‫هل توجد مشكالت في حركة المرور ؟ ?‪There is any problem in traffic management‬‬
‫?‪No strong wind / rain condition‬‬ ‫اليوجد رياح او امطار قوية ؟‬
‫ضع عالمة ( √) إذا كانت منطــقة العمل جاهــزة‬
‫?‪Use proper tag line to control all loads‬‬ ‫استخدام حبال لتوجية الحمل؟‬
‫‪Put ( √ )if the work area is ready and safe‬‬
‫? ‪Appropriate PPE provided‬‬ ‫هل تم استخدام مهمات السالمة الشخصية‬
‫‪Is The pre-use inspection has been for hooks,chains ,pullys ,limit swich‬‬
‫?‪and in good condition‬‬ ‫هل تم عمل فحص الهوكات‬
‫قبل اإلستخدام وأن جميعها بحالة جيدة ؟ ‪ ,‬والذراعو مفتاح االيقاف المحدد ‪ ،‬السالسل ‪ ،‬البكرات‬
‫هل منطقة العمل حول الرافعة المجنزرة مؤمنة ؟‬
‫? ‪The work area around is secured and barricaded‬‬
‫خلف‬ ‫?‪Communication devices and in good condition‬‬ ‫وسائل االتصال بحالة جيدة؟‬
‫?‪Load within SWL‬‬ ‫الحمولة في مدي الحمل اآلمن ؟‬
‫أنا ‪ /‬نحن استلمت تصريح العمل وتم فحص اجراءات السالمة قبل العمالل وعلالى درايالة بمتطلبالات السالالمة فياله والخاصالة‬
‫يجب االمتثال لكل ماورد في التصريح اثناء الرفع‬ ‫بالعمل الذي أقوم به ‪ .‬وسوف أقوم ‪ /‬نقوم باتباع وتنفيذ تعليمات السالمة ‪ .‬وسنقوم بإيقاف العمل إذا ما كان الوضع غير‬
‫‪Work Shall carry out only after complying with this permit.‬‬
‫آمالالن وسالالنخطر المسالالؤول عالالن ذلالالك ‪Cometment: I Know all hazards and measure control .‬‬
‫‪-‬‬ ‫‪related to my work , and I will follow safety insturctions and stop the work in case‬‬
‫‪of hazard‬‬
‫توقيع مشغل الرافعة ‪................................................................................ Operator /‬‬
‫توقيع موجه الرافعة ‪...................................................................... Rigger )1)/‬‬
‫توقيع موجه الرافعة ‪...............................................................................Rigger (2) /‬‬
‫‪.........................................................................................................................‬‬
‫‪..............................................................................‬‬
‫‪.........................................................................................................................‬‬
‫توقيع مسؤول السالمة‬ ‫المدير التنفيذي‬ ‫توقيع مسئوول الرافعة‬ ‫توقيع مشرف السالمة‬
‫‪...........................................‬‬ ‫‪...........................................‬‬ ‫‪........................................‬‬

‫‪............................................................................................‬‬ ‫وقت إيقاف الرافعة‬ ‫تاريخ اإليقاف‬
‫‪..................................................................‬‬ ‫‪.........................................................‬‬
‫*تم التأكد من توفير جميع المتطلبات الخاصة بعملية الرفع وعلى ذلك يتم تحميل مسؤول الرفع بالموقع (مهندس التنفيذ) كامل المسؤولية في حال اإلخالل بإشتراطات ومتطلبات أنظمة السالمة‬

GENERATOR INSPECTION REPORT

Date Modified:
Equip Name /‫إسم المعدة‬ GENERATOR

Date / ‫التاريخ‬ Location/ ‫المكان‬
Generator No. /‫رقم المولد‬ Company/‫الشركة‬

Capacity /‫القدرة‬ Generator Type/‫نوع المولد‬
S. N Code No. / ‫رقم الكود‬
Model No. / ‫الموديل‬ Rating/ ‫التقييم العام‬
No. Tuv ‫رقم‬ Expire Date /‫تاريخ االنتهاء‬
Comments/ ‫مالحظات‬ Engine/‫المحرك‬
1
Ok Not ok
Comments/ ‫مالحظات‬ ‫مولد التيار البديل‬
2
Ok Not ok
Comments/ ‫مالحظات‬ Fuel System/‫تظام التزود بالوقود‬
3
No Yes
Comments/ ‫مالحظات‬ Voltage Regulator/‫منظم الجهد‬
4
Ok Not ok
Comments/ ‫مالحظات‬ Fan /‫المروحة‬
5
Ok Not ok
Ventilation ‫نظام التبريد التهوية‬
System/ 6
Ok Not ok
Comments/ ‫مالحظات‬ Battery Charge/‫شاحن البطارية‬
7
Ok Not ok
Comments/ ‫مالحظات‬ Control Panel /‫لوحة التحكم‬
8
Ok Not ok
Comments/ ‫مالحظات‬ Main Frame /‫اطار التجميع الرئيسي‬
9
Ok Not ok
Isolation ‫كل الكابالت معزولة ومؤمنة‬
Cables / 10
Ok Not ok
Comments/ ‫مالحظات‬ Oil Leakage /‫ال يوجد تسريب للزيت‬
11
Comments / ‫مالحظات‬ Air Pressure Filter / ‫فلتر ضغط الهواء‬ Ok Not ok
Ok Not ok Comments/ ‫مالحظات‬ Fire Extinguisher /‫طفاية حريق مناسبة‬
12
Ok Not ok
Comments / ‫مالحظات‬ Oil Filter / ‫فلتر الزيت‬ Comments/ ‫مالحظات‬ Secure point /‫نقطة التثبيت آمنة‬
Ok Not ok 13
Ok Not ok
Comments/ ‫مالحظات‬ Emergency Key/‫مفتاح الطواريء‬
14
Ok Not ok
Comments/ ‫مالحظات‬ Conveyors/‫السيور‬
15
Ok Not ok
...................................................................................................................................................................................................................: Comment / ‫مالحظات حول الرافعة‬
Signature / ‫توقيعه‬ Electrician Name/ ‫إسم الكهربائي‬
.......................................................................................................................................................................................................................................................

‫‪GENERATOR INSPECTION REPORT‬‬

‫قائمة الفحص اليومي لوحدات التوليد الكهربائية‬
‫رقم المولد‪.......................... :‬‬ ‫الوقت ‪................................ :‬‬ ‫التاريخ‪........./............/.............. :‬‬
‫السعة (‪…………………. : )KVA‬‬ ‫اسم المورد ‪............................ :‬‬ ‫جهة الخدمة ‪.................................. :‬‬
‫‪1‬‬
‫نظام التبريد‬ ‫غير متزن‬ ‫متزن‬ ‫اتزان المولد على القواعد‬
‫منخفض‬ ‫مقبول‬ ‫مستوي المياة‬ ‫البطاريات‬

‫‪11‬‬
‫درجة الحرارة ( ‪)C‬‬ ‫ضعيفة‬ ‫حالة البطاريات‬ ‫‪2‬‬
‫جيدة‬
‫ال تعمل‬ ‫تعمل‬ ‫حالة المضخة‬ ‫ضعيف‬ ‫جيد‬ ‫ربط االطراف‬
‫زيت التشحيم‬ ‫ال يعمل‬ ‫يعمل‬ ‫حالة الشحن‬
‫ضغط الزيت (بار)‬ ‫الجهد بالفولت‬

‫‪12‬‬
‫الجهود على الفازات الثالثة (فولت)‬ ‫‪3‬‬
‫حرارة الزيت ( ‪)C‬‬ ‫‪/‬‬ ‫‪/‬‬
‫التيار للفازات الثالثة (امبير)‬ ‫‪4‬‬
‫غير مقبول‬ ‫مقبول‬ ‫مستوي الزيت‬ ‫‪/‬‬ ‫‪/‬‬
‫التردد (هرتز) ‪60±1‬‬ ‫‪5‬‬
‫نظام الوقود‬
‫‪13‬‬
‫مستوي الوقود‬ ‫)‬ ‫الحمل ( ‪KVA‬‬ ‫‪6‬‬
‫‪%‬‬
‫بالخزان‬
‫السرعة ( ‪1800±30) RPM‬‬ ‫‪7‬‬
‫العادم‬
‫‪14‬‬
‫تسريب بداخل‬
‫يوجد‬ ‫ال يوجد‬ ‫القاطع الكهربائي الرئيسي للمولد‬
‫الحاوية‬ ‫‪8‬‬
‫حالة السيور‬ ‫القيمة‪:‬‬ ‫ضبط تيار زيادة الحمل ‪0.4‬‬
‫سيور مروحة‬
‫ضعيف‬ ‫متوسط‬ ‫قوي‬ ‫‪15‬‬ ‫القيمة‪:‬‬ ‫‪9.0‬‬ ‫ضبط تيار القصر‬
‫التبريد ‪ -‬الشد‬
‫سير الدينامو‬
‫ضعيف‬ ‫متوسط‬ ‫قوي‬ ‫القاطع الرئيسي للوحة الكهربائية المتصلة بالمولد‬
‫‪ -‬الشد‬ ‫‪9‬‬
‫الموعد المحدد لتغيير الفالتر‬ ‫القيمة ‪:‬‬ ‫ضبط زيادة الحمل ‪0.2‬‬
‫لم يتم‬ ‫تم فى الموعد‬ ‫فلتر الهواء‬ ‫القيمة‪:‬‬ ‫ضبط تيار القصر ‪8.0‬‬
‫لم يتم‬ ‫تم فى الموعد‬ ‫فلتر الوقود‬ ‫نظام التأريض الكهربائي‬

‫‪16‬‬ ‫‪10‬‬
‫لم يتم‬ ‫تم فى الموعد‬ ‫فلتر (فاصل المياة)‬ ‫غير موجود‬ ‫موجود‬ ‫تاريض نقطة التعادل‬
‫لم يتم‬ ‫تم فى الموعد‬ ‫فلتر الزيت‬ ‫غير موجود‬ ‫موجود‬ ‫تاريض الحماية‬
‫‪TNS‬‬ ‫‪TNC‬‬
‫القطع المتهالكة ويلزم استبدالها (ان وجدت)‬ ‫نوع نظام التاريض‬
‫‪17‬‬ ‫للخدمات‬ ‫لالوناش‬
‫ا‪-‬‬
‫ب‪-‬‬
‫ج‪-‬‬
‫توقيعات لجنة الفحص‬
‫مدير المنطقة‬ ‫مندوب السالمة‬ ‫مندوب المورد‬ ‫مندوب قسم الكهرباء والميكانيك‬
‫إسم‪/‬‬ ‫إسم ‪/‬‬ ‫إسم ‪/‬‬ ‫إسم ‪/‬‬
‫توقيع‪/‬‬ ‫توقيع‪/‬‬ ‫توقيع‪/‬‬ ‫توقيع‪/‬‬

GENERATOR INSPECTION REPORT

Date Modified:
Diesel Filling Permit ‫تصريح تعبئة ديزل‬

‫الوقت‬ ‫التاريخ‬ ‫اليوم‬
Time Date Day
Inspection items must be marked “OK” if in good condition, “X” if damaged

‫(فى حالة غير مطابق لمعايير السالمة‬X) ‫( إذا كان المولد بحالة جيدة او عالمة‬OK) ‫يجب وضع عالمة‬
Generator Case ‫حالة المولد‬ ‫رقم المولد‬

Comment‫مالحظات‬ No. of Generator
OK X
‫مسؤول السالمة‬ ‫توقيع مراقب العمل‬

Safety signature Foreman Signature

SAFETY CHECKLIST FOR WELDING & CUTTING TOOLS

Date Modified:
SAFETY CHECKLIST FOR WELDING AND CUTTING TOOLS

‫فحص سالمة األدوات الخاصة باعمال اللحام‬
PROJECT: ‫المشروع‬
LOCATION: ‫الموقع‬
DATE : ‫التاريخ‬
№ WELDING AND CUTTING ‫اللحام و القطع‬ Yes No Comment

Operators Qualified
1 ‫العامل او المشغل مؤهل‬
Complete Prescribed Personal Protective Equipment
2 ‫تأمين معدات السالمة الشخصية المناسبة‬
Equipment in Safe Operating Condition
3 ‫معدات التشغيل بحالة جيدة‬
Electrical Equipment Grounded
4 )‫تأريض المعدات الكهربية (التوصيل االرضي‬
Cables Protected and in Good Repair
5 ‫التوصيالت بحالة جيدة و مؤمنة‬
Proper Fire Extinguishers Readily Available
6 ‫توفير طفاية حريق مناسبة‬
Inspection for Fire Hazards
7 ‫التفتيش عن مخاطر الحرائق في موقع اللحام‬
Gas Cylinders Chained Upright
8 ‫تقييد إسطونات الغاز بسالسل بوضع صحيح رأسي‬
Gas Hoses Protected & in Good Condition
9 ‫خراطيم الغاز محمية و في حالة جيدة‬
Cylinder Caps in Used
10 ‫استخدام اغطية األسطونات‬
Warning Sign Posting & Barricading
11 ‫حواجز وعالمات تحذير‬
Stand-By Watchman
12 ‫رجل للمتابعة‬
Details of the person’s conducting the check ‫معلومات الشخص الذي قام بالفحص‬
Report by ‫إعداد‬ Checked and approved by ‫مراجعة وتصديق‬
Name: ‫االسم‬ Name: ‫االسم‬
Job Title: ‫الوظيفة‬ Job Title: ‫الوظيفة‬

Comments attached ‫ترفق المالحظات‬

CRITICAL LIFTING PLAN FOR FORM

Date Modified:
Project : Area: Date:

1
Submitted for Approval before 72 hours commencement of activity
Activity Discretion :
2
3 Wight of Load:
Equipments Used / Capacities (SWL) :

4
5 Color Code :
All Lifting Operation Require the Following to be Considered:

1-Weight, size, shape and CG of load.
2-Method of slinging /attach/de-attach.
3-Availability of approved lifting point on load.
4-Pre-use equipment checks by operator.
5- Path of load, Obstructions
6-Conflicting tasks in the area.
7-Working under suspended loads.
8- working above suspended loads
9-Need for tag line.
6 10-Environmental condition.
11-Competence of personnel.(crane operator/riggers)
12-No. of People required for task.
13-Communication requirements.
14-Banks man.
15-Soil condition under crane / crane outriggers
16-Tailing / turning the lift.
17- Included angle between wire ropes
18- Crane operator certificate
19-Lifting equipments certificates
20-Distance from adjacent excavation and power electrical line

Task details:
1-Position lifting crane(. ….ton ) in position
2- Position tailing crawler crane in position (……..ton)
3-Sling the load.
4-Lift the load.
5-Adjust Crane to have the correct (safe) radius needed for final installation of the load.
7
5-Lift the load to its final position.
6-Loose the load, secure it, complete activity.
7-Remove slinging.
8-Remove barriers
9-Untracked cranes.
10-Demobilize lifting crew.
Pre-lift Checks:
1-Cranes conditions.
2- Mobilize lifting crew.
3-Check all loose lifting gears.
8 4-Escape routes are clear.
5-All lifting area is barrier.
6-Carry out functional test on crane.
7-Mobilize cranes at lifting area.
8-Position cranes onto proper position.
9 Method of Communication:
T.B.T:
10
Lifting crew must receive a T.B.T before carrying out the lifting operation
PPE Required:
11
Attachments:
1-Copy of crane operator certificate
12
2- Copy of lifting equipments certificate
3- Diagram / Sketch Of Lifting Operation as needed
Prepared by: Name : Signature :
Reviewed by: Name : Signature :
Approved by: Name : Signature :

SCAFFOLD CHECKLIST ‫فحص السقاالت‬
Date Modified:
Project Name ‫اسم المشروع‬ Date ‫التاريخ‬
Contractor Name ‫اسم المقاول‬ PTW No. ‫رقم تصريح العمل‬
Type of Scaffold Erection / Dismantling ‫ تفكيك‬/ ‫ تشييد‬- ‫نوع العمل على السقالة‬
 Frame  System Scaffold  Green Tagged  Engineered
 Tube & Clamp  Other  Yellow Tagged
Describe Location of Scaffold: Yellow Tag Restrictions:
Installation Date: Last Inspection Date:

Identified Compliant
Qualifications of Scaffold Erectors ‫مؤهالت القائم على تعديل السقالة‬ Notes
(Y/N) (Y/N)
1 Review training records ‫مراجعة سجل التدريب‬
2 Review Trade Qualification Certificate ‫مراجعة شهادة االعتماد‬

Engineered Scaffolding Notes
(Y/N) (Y/N)
Confirm size & height of scaffold is as per Drawing
1
‫توافق االبعاد مع التصميم‬
Engineering Documents - Stamped Drawing & Approval letter
2
‫الوثائق الهندسية المعتمدة‬
Verify scaffold erection to drawing provided
3
‫تركيب السقالة وفقا للرسم المعتمد‬
4 Cantilever support system being used ‫نظام دعم الكابولي المستخدم‬
Suspended Platforms drawings are Engineered & Stamped
5
‫توفير رسومات لمنصة العمل المعلقة‬
6 Review Scaffold specifications ‫مراجعة مواصفات السقالة‬
7 Review Platforms specifications ‫مراجعة مواصفات منصة العمل‬

Review Rescue Plan & equipment available
8
‫مراجعة خطة اإلخالء والمعدات المتاحة‬
Scaffold Details Review ‫مراجعة تفاصيل السقالة‬ Notes
(Y/N) (Y/N)
1 Review access points ‫مراجعة أماكن الدخول‬
2 Identify tie off points / travel restraint ‫تحديد نقاط الربط والمسافة بينهما‬
Ensure size & quality of platform for scaffolds is adequate

3
‫ابعاد وكفاءة منصة العمل مناسبة‬
Ensure anchor points / outriggers / secured to structure
4
‫التأكد من كفاءة نقاط االرتكاز والدعم للسقالة‬
5 Review condition of scaffold components ‫فحص حالة أجزاء السقالة‬

Ensure applicable weight capacity affixed to the scaffold
6
‫التأكد من قدرة السقالة على تحمل الوزن المسموح‬
Check handrail, mid rail, toe board

7
‫فحص الدرابزين األعلى واألوسط وحاجز االدوات‬
Check ladder location & cage enclosure
8
‫فحص موقع السلم ومدى قرب مسافة قفص الحماية‬
Ensure grounding to structural steel for welding
9
‫التأكد من توصيل االرضي في حالة اعمال اللحام‬
Daily Inspection check / date of inspection & signature

10
‫الفحص اليومي وتاريخ الفحص والتوقيع‬
11 Review covers for holes ‫فحص تغطية الفتحات‬
Confirm rope off area below scaffolding

12
‫إحاطة منطقة السقالة بشريط تحذيري‬
Review procedures for working in unprotected areas
13
‫مراجعة اإلجراءات في مناطق العمل غير اآلمنة‬
14 Review general housekeeping ‫مراجعة النظافة العامة‬
Modification Review ‫مراجعة التعديالت‬ Notes
(Y/N) (Y/N)
Modifications approved by Engineer of Record?
1
‫هل تم اعتماد سجل التعديالت من قبل المسئول‬
Hazard Identification and Assessment Screens Reviewed?

2
‫هل تم مراجعة تحديد المخاطر وتقييمها؟‬
Fall Prevention / Protection Selection Considerations Reviewed?

3
‫هل تم مراجعة وسائل الحماية من السقوط؟‬
4 Fall Prevention / Protection Options Reviewed?
Falling Objects Control reviewed?

5
‫هل تم مراجعة طرق التحكم في المواد المتساقطة؟‬
Reviews & Approvals
Approved ‫الموافقة‬
Modification Review Name/Company
Date: ‫التاريخ‬ Signature: ‫التوقيع‬
‫تاريخ التعديل‬ Yes No N/A ‫الشركة‬/‫االسم‬

SCAFFOLD ERECTION REQUEST ‫فحص السقاالت‬
Date Modified:
Contractor/Subcontractor: _________________________________
Contractor/Subcontractor: ____________________ Area ________________________________ Date
Area ________________________________ __________________
Date __________
Specific Location ___________________________________________________Scaffold number _________________________________________________

Location ___________________________________________________Scaffold number _______________________
Supervisor __________________________________________________________
Supervisor __________________________________________ Builder
Builder __________________________________________________________
____________________________________________
(Printname)
(Print name) (Printname)
(Print name)
Purposeof
Purpose ofScaffold
Scaffold ______________________________
__________________________________________Length
Lengthofof Time
Time Needed
Needed __________________________________
___________________________
Type of
Type of Scaffold_________________________________
Scaffold _________________________________ MaximumMaximum
Number of personnel
Number Permitted
of personnel _________________________
Permitted ____________
Height _________________________________________
Height ____________________________ Length at Length
Base _______________________________________________________
at Base ________________________________
Width
Width at
atbase
base _______________________ Load
_________________________________ Load Limit Limit Maximum
Maximum = Total Kg=_____________________________________
Total Kg ___________________
NOTE:
NOTE: Design drawing
Design drawingand
andspecifications must
specifications be attached
must for special
be attached scaffold
for special or an engineer
scaffold designed
or an engineer scaffold.scaffold.
designed
9PRE-ERECTION APPROVALS
The signatories below agree to the information above.
User ______________________ Date ____________ Scaffolding Superintendent _______________________ Date __________________
Safety_____________________ Date_____________ Construction Manager _____________________________ Date __________________
SCAFFOLD COMPLETION
By signing here the scaffold builder verifies that the scaffold is complete, the scaffolding supervisor verifies that he has
conducted an inspection and confirms that the scaffold is complete and that is it being build according to the information
on this document and that the scaffold is ready for inspection. The user signs verifying that the scaffold is built according to
his needs.
Scaffold Builder ________________________________________________ Date Completed ________________
Scaffolding Supervisor________________________________________ Date _________________________
Scaffold User __________________________________________________ Date _________________________
AFTER ERECTION INSPECTION AND APPROVAL

By signing below the Scaffolding Superintendent and the Competent Scaffold Inspector certifies that the scaffold is
complete, meets all the scaffolding and safety criteria and that it is safe for use. The scaffold inspection form must be used
for the inspection of the scaffold. A completed green SCAFTAG must be attached to the scaffold at the access point with the
scaffold number written on the SCAFTAG.(In case of a specialty scaffold or engineered design scaffold or a scaffold 9 meters
and above in height, the Scaffolding Engineer must sign as the Competent Scaffold Inspector.)
Competent Scaffold Inspector ___________________________________________ Date _____________________
Scaffold Superintendent _________________________________________________ Date _____________________

OFFICE SAFETY INSPECTION ‫التفتيش على المكاتب‬
Date Modified:
Inspection Date Location/ Level:

Work Environment Safety
#. Description Yes No. Corrective Action / Comment
1 Employees Work areas are adequately illuminated
Employees work areas are clean, orderly and don't present a
2
hazard
3 Aisles correctly established and clear
4 No tripping hazards in evidence
5 Floors dry – not slippery
6 Cords not stretched across aisles
7 Adequate lightening in stairways, aisles and storage rooms
8 Stairways clear
9 Stair treads in good condition
10 Handrails installed and in good condition
11 Halls kept clear of equipment and supplies
12 Emergency exit doors clearly marked and accessible
13 Fire extinguishers accessible and fully charged
14 Emergency lights are available and functional
15 Smoke detectors are available and functional
16 Bookcases and shelves not overloaded
17 Heavy Storage shelves secured to wall
18 File drawer closed when not in use
19 Electrical outlets not overloaded
20 Equipment property grounded (3 pronged plugs)
21 Electrical cords and plugs in good condition
22 Extension cords not substituted for permanent wiring
23 Chairs in good mechanical condition
24 Paper cutter equipped with guard / blade spring functioning
25 Safe step stools and ladders properly used when needed
26 Paper shredder guarded
27 Unobstructed air movement and vents
Prepared By Reviewed By Approved By

‫‪DAILY ENVIRONMENTAL INSPECTION REPORT‬‬
‫‪Daily Environmental Inspections‬‬ ‫أعمال التفتيش البيئي اليومي‬

‫‪/‬‬ ‫‪/‬‬ ‫التاريخ ‪:‬‬ ‫‪20‬‬
‫أثناء المرور والتفتيش على الموقع تم تنفيذ وعمل اآلتي ‪-:‬‬ ‫‪‬‬
‫)‪.‬‬ ‫‪ .1‬متابعة أعمال رفع وتجميع المخلفات المكتبية فى منطقة (‬

‫‪ .2‬متابعة أعمال رفع المخلفات المكتبية إلى مجمع النفايات ‪.‬‬
‫‪ .3‬متابعة أعمال النظافة في إستراحة العمال ‪.‬‬
‫‪ .4‬متابعة أعمال رفع المخلفات من مجمع النفايات ووضعها فى القالبات إلزالتها من الموقع ‪.‬‬
‫)‪.‬‬ ‫) رقم المكتب (‬ ‫‪ .5‬الكشف عن التسريبات فى المكاتب منطقة (‬
‫)‪.‬‬ ‫) رقم المكتب (‬ ‫‪ .6‬الكشف عن المخلفات أسفل المكاتب منطقة (‬
‫األتربة) ‪.‬‬ ‫الضوضاء‬ ‫سرعة الرياح‬ ‫الرطوبة‬ ‫درجة الحرارة‬ ‫‪ .7‬أخذ قياسات الرصد البيئي(‬
‫‪ .8‬متابعة أعمال رش المياه فى الموقع والطريق ‪.‬‬
‫)‪.‬‬ ‫‪ .9‬التشييك على خزانات المياه التابعة لمكاتب منطقة (‬
‫‪ .10‬الكشف عن التسريبات فى األماكن المغلقة ‪.‬‬
‫‪ .11‬اخذ القياسات لنسبة الغازات فى األماكن المغلقة ‪.‬‬
‫‪.‬‬ ‫( التابع للمهندس ‪/‬‬ ‫‪ .12‬التفتيش البيئي على ‪) ZONE‬‬
‫مالحظات أخرى على البنود‬

‫‪-:‬‬

‫‪Daily Environmental Inspection of the Site of the Environmental Unit‬‬
‫التفتيش البيئي اليومي للموقع الخاص بوحدة البيئة‬
‫‪Information‬‬ ‫معلومات‬
‫قراءات االجهزة المستخدمة‬

‫فحص بواسطة المفتش ‪:‬‬
‫الرطوبة ‪:‬‬ ‫قياس شدة الحرارة ‪:‬‬
‫مستوى األتربة ‪:‬‬ ‫سرعة الرياح ‪:‬‬ ‫تاريخ فحص المنطقة ‪:‬‬
‫الضوضاء ‪:‬‬ ‫مدة فحص المنطقة ‪:‬‬
‫‪Hygiene‬‬ ‫النظافة‬
‫غير جيد‬ ‫جيد‬ ‫النظافة العامة ‪:‬‬
‫غير جيد‬ ‫جيد‬ ‫نظافة الممرات والطرق ‪:‬‬
‫غير جيد‬ ‫جيد‬ ‫توفير مياه مخصصة للشرب ‪:‬‬
‫غير جيد‬ ‫جيد‬ ‫مطابقة مواصفات المياه للقياسات السعودية‪:‬‬
‫غير جيد‬ ‫جيد‬ ‫مستوى رش الموقع بالمبيدات الحشرية ‪:‬‬
‫غير جيد‬ ‫جيد‬ ‫نظافة فالتر المياه ‪:‬‬
‫غير جيد‬ ‫جيد‬ ‫نظافة دورات المياه ‪:‬‬
‫‪Dusts‬‬ ‫األغبرة‬
‫غير جيد‬ ‫جيد‬ ‫مستوى األغبرة ‪:‬‬
‫اليوجد‬ ‫يوجد‬ ‫رش المياه في الموقع ‪:‬‬
‫ال يوجد‬ ‫يوجد‬ ‫رش المياه في الطرق والممرات‪:‬‬
‫اليوجد‬ ‫يوجد‬ ‫إستخدام العوازل ‪:‬‬
‫غير جيد‬ ‫جيد‬ ‫إلتزام العاملين ‪: PPE‬‬
‫‪Noises‬‬ ‫الضوضاء‬
‫غير جيد‬ ‫جيد‬ ‫مستوى الضوضاء ‪:‬‬
‫اليوجد‬ ‫يوجد‬ ‫إستخدام العوازل ‪:‬‬
‫غير جيد‬ ‫جيد‬ ‫إلتزام العاملين ‪: PPE‬‬

‫‪Leaks‬‬ ‫التسريبات‬
‫ال يوجد‬ ‫يوجد‬ ‫تسريبات مياه ‪:‬‬
‫ال يوجد‬ ‫يوجد‬ ‫تسريبات المشتقات البترولية‪:‬‬
‫ال يوجد‬ ‫يوجد‬ ‫تسريبات كيميائية ‪:‬‬

‫‪Lighting‬‬ ‫اإلضاءة‬
‫غير جيد‬ ‫جيد‬ ‫مستوى اإلضاءة ‪:‬‬
‫صناعية‬ ‫طبيعية‬ ‫نوع اإلضاءة ‪:‬‬
‫‪Ventilation‬‬ ‫التهوية‬
‫غير جيد‬ ‫جيد‬ ‫مستوى التهوية ‪:‬‬
‫ال يوجد‬ ‫يوجد‬ ‫إستخدام التهوية الصناعية في المناطق الحارة ‪:‬‬
‫الصرف الصحى ‪Sanitation‬‬

‫غير جيدة‬ ‫جيدة‬ ‫مستوى تصريف الفضالت والمياه ‪:‬‬
‫‪Stores and confined Space‬‬

‫المستودعات واألماكن المغلقة‬
‫اليوجد‬ ‫يوجد‬ ‫مواد خطرة ‪:‬‬
‫اليوجد‬ ‫يوجد‬ ‫‪:‬‬ ‫تسريبات‬
‫غير جيد‬ ‫جيد‬ ‫التهوية ‪:‬‬
‫اليوجد‬ ‫يوجد‬ ‫اإلضاءة ‪:‬‬
‫غير جيد‬ ‫جيد‬ ‫طريقة تخزين المواد ‪:‬‬
‫اليوجد‬ ‫يوجد‬ ‫غازات ‪:‬‬
‫غير جيد‬ ‫جيد‬ ‫نسبة االكسوجين ‪:‬‬
‫اليوجد‬ ‫يوجد‬ ‫درجة الحرارة ‪:‬‬
‫غير جيد‬ ‫جيد‬ ‫المنطقة ‪:‬‬

‫‪ ‬في حالة وجود مالحظات حول التفتيش ‪:‬‬
‫المستودعات واألماكن المغلقة‬ ‫إضاءة‬ ‫تسريبات‬ ‫ضوضاء‬ ‫أغبرة‬ ‫نظافة‬ ‫طبيعة المالحظة البيئية ‪:‬‬
‫الشركة المسؤولة عن‬

‫منطقة تواجد المالحظة‬
‫المالحظة المذكورة‬
‫وقت رصد المخالفة‬ ‫أسم مسؤول عن المنطقة‬
‫الوقت الممنوح إلزالة المالحظة المذكورة‬
‫اإلجراءات التى تم إتخاذها ‪Actions taken‬‬

‫مسئول وحدة البيئة‬ ‫مفتش السالمة‬

‫‪:‬‬ ‫اإلسم‬ ‫‪:‬‬ ‫اإلسم‬
‫التوقيع ‪:‬‬ ‫التوقيع ‪:‬‬

DAILY ENVIRONMENTAL INSPECTION REPORT
Date Modified:
Spraying Environment Works

Daily spraying and pest control / / ‫أعمال الرش ومكافحة الحشرات اليومية عن يوم‬
Remark Location Time Type of Spry

‫مالحظات‬ ‫اماكن الرش‬ ‫التوقيت‬ ‫نوع الرش‬
Smoke ‫دخان‬
Odorless spray ‫بخاخ بدون رائحة‬
Smell spray ‫بخاخ برائحة‬
Anti-rat ‫مكافحة الفئران‬
‫مسؤول وحدة البيئة‬ ‫مفتش البيئة‬ ‫مسؤول أعمال الرش‬
‫التوقيع‬ ‫التوقيع‬ ‫التوقيع‬

Date Modified:
Environmental inspection of offices ‫التفتيش البيئى على المكاتب‬

‫القسم‬ ‫رمق املكتب‬
Remark ‫املالحظات‬ Leaks ‫الترسيبات‬ Clean under the desk ‫النظافة أسفل املكتب‬ ‫م‬
Department Office No
2
10
/ / :‫التاريخ‬
‫مسؤول وحدة البيئة‬ ‫مفتش السالمة‬
: ‫االسم‬ : ‫االسم‬
:‫التوقيع‬ :‫التوقيع‬

Date Modified:
Environmental Waste Collection

1- Number of the Waste to the Site ‫حصر المخلفات بالموقع‬
‫ من‬/ / ‫م الى‬20 / / ‫م‬20
Remark No of removal Waste Status Type of waste Location Date
‫م‬
‫مالحظات‬ ‫عدد مرات الرفع‬ ‫الحالة‬ ‫نوع المخلفات‬ ‫المنطقة‬ ‫التاريخ‬

:‫اإلسم‬ :‫اإلسم‬

2- Survey and Removing the Landfill Waste Site ‫حصر ورفع مخلفات المكب بالموقع‬
‫م‬20 / / ‫إلى‬ ‫م‬20 / / ‫من‬

No. Type of Waste
Remark Remove Status ‫نوع المخلفات‬ Location Date
‫م‬
‫مالحظات‬ ‫عدد مرات‬ ‫الحالة‬ Wood Plastic Paper Solid ‫المنطقة‬ ‫التاريخ‬
‫الرفع‬ ‫خشبية‬ ‫بالستيك‬ ‫ورقية‬ ‫صلبة‬
1
10
11
12
‫ ايمن مجلد‬/‫ م‬:‫اإلسم‬ ‫ محمود حسن‬:‫اإلسم‬

Date Modified:
Environmental Monitoring Record (Measuring Devices) on the Site

‫سجل الرصد البيئي (أجهزة القياس) بالموقع‬
Temperatures Wend Speed Dust Date Day
‫م‬
‫الحرارة‬ ‫الرياح‬ ‫الغبار‬ ‫التاريخ‬ ‫اليوم‬
‫السبت‬ 1
‫األحد‬ 2
‫اإلثنين‬ 3
‫الثالثاء‬ 4
‫األربعاء‬ 5
‫الخميس‬ 6
‫مسؤول وحدة البيئة‬ ‫مفتش قسم البيئة‬

Date Modified:
Environmental Monthly Report for Monitor the Wind
Monthly Report for Monitor The Wind During Month ...................... ‫تقرير متابعة حركة الرياح خالل شهر‬
No. of stop work Hr. Wind Speed Time
‫عدد ساعات توقف العمل‬ ‫رسعة الرايح‬ ‫الوقت‬ Date SN
Stop and Evacuation Crane Stop To From To From ‫التارخي‬ .‫م‬
‫ايقاف واخالء املوقع‬ ‫ايقاف الرافعات‬ ‫اىل‬ ‫من‬ ‫اىل‬ ‫من‬

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
‫إدارة السالمة والبيئة والصحة المهنية بمشروع توسعة المسجد الحرام والعناصر المرتبطة به‬

VISITOR ORIENTATION CHECKLIST
‫إجراءات تعريفية للزائرين‬
Date Modified:
Project Name: Date

Purpose Of Visit:
Visitor Name(S):
1. _______________________________ 2. _________________________________
3. _______________________________ 4. _________________________________
5. _______________________________ 6. _________________________________
7. _______________________________ 8. _________________________________
Emergency Procedures
Emergency Phone Number: ______________________________________________________
Evacuation Assembly Point: ______________________________________________________
Personal Protective Equipment (PPE) Requirements
Hard Hat
Safety Glasses (with side shields)
Protective Clothing Requirements
Hearing Protection Requirements (Posted Areas)
Appropriate Footwear
Visitor Responsibilities
 Report to host any unsafe condition or activity observed
 Report to host injury or adverse health effects experienced
 Comply with all posted signs, tags, and barricades
 Comply with all requirements, including smoking restrictions
Visitor Restrictions
Visitors are not permitted to:
 Perform work without authorization
 Tour unescorted
 Remove any property from premises without authorization
 Bring cameras, video production and other photographic equipment without prior authorization
Orientation Conducted By:
_________________________________________ _________________________________________
Printed Name / Department Signature
Visitor Signatures:
_______________________________ _________________________________
_______________________________ ________________________________
_______________________________ _________________________________
_______________________________ _________________________________

ELECTRICAL PANELS INSPECTION
Date Modified:
EQ. Name : ‫اسم المعدة‬ Electrical Panels ) ‫( فحص لوحات الكهرباء‬

Generator No./‫رقم المولد المغذي‬ Panel No./ ‫رقم اللوحة‬
Lighting Panel/ ‫لوحة اإلنارة‬ Inspection Date/‫تاريخ الفحص‬
Coordinates/ ‫اإلحداثيات‬ Y: X: Main Panel/‫لوحة رئيسية‬
‫منطقة التغذية‬ ‫اللوحة المغذية‬
‫وجود‬GFCI-RCPO
4 3 2 1 Comments 1
No Yes
‫تأريض لوحة الكهرباء‬GROUNDING/
Comments
2
No Yes
‫ترقيم لوحة الكهرباء‬NUMBERING/
Comments 3
No Yes
/ ‫مالحظات‬ ‫(نموذج الصيانة الدورية(قسم اإللكتروميكانيكال‬
7 5 Comments Maintenance Sheet
4
6 No Yes
/ ‫مالحظات‬ ‫الغطاء الخارجي مثبت و محكم‬
Comments External COVERED 5
No Yes
/ ‫مالحظات‬ ‫تسمية قواطع اللوحة الكهرباء‬
Comments LABELING/
6
No Yes
/ ‫مالحظات‬ ‫عدم وجود أسالك متشابكة و ملتفة حول بعضها البعض‬
Comments Tangled wires/ 7
No Yes
‫عزل اللوحة ضد األمطار‬RAIN PROOFING/
Comments 8
No Yes
/ ‫مالحظات‬ ‫جميع األسالك الداخلة والخارجة معزولة جيدا‬
Comments INT&EXT CABLES INSULATED/
9
No Yes
/ ‫مالحظات‬ ‫النظافة والترتيب بمحيط لوحة الكهرباء‬
Comments Housekeeping
10
No Yes
........................................................................................................................................................................................................ : Comment / ‫مالحظات حول الرافعة‬

...............................................................................................................................................................................................................................................................

Signature / ‫توقيعه‬ Electrician /‫فني الكهرباء‬
Signature / ‫توقيعه‬ Electricity Engineer/ ‫مسؤول قسم االكهرباء‬
( / / ):: (Exclusion Date( in case the crane excluded, please reason for exclusion ) / / : ‫( تاريخ اإلستبعاد‬ ‫في حال إستبعاد الرافعة الرجاء ذكر سبب اإلستبعاد‬
..........................................................................................................................................................................................................................................

FLOOD LAMP INSPECTION
Date Modified:
EQ. Name : ‫اسم المعدة‬ Flood Lamp – ‫كشافات اإلنارة‬

Capacity/‫قدرة الكشاف‬ Flood No./ ‫رقم الكشاف‬
Coordinates/ ‫اإلحداثيات‬ Date of Inspection/ ‫تاريخ الفحص‬

Comments / ‫مالحظات‬ Electricity Key /‫مفتاح الكهرباء‬

2 1
No Yes
Comments / ‫مالحظات‬ Safety Cables / ‫سالمة كابالت الكهرباء‬
No Yes
Comments / ‫مالحظات‬ Electrical Lamp/ ‫لمبة الكشاف‬
No Yes
Comments / ‫مالحظات‬ Hand Of Flood / ‫يد الكشاف‬
No Yes
Comments / ‫مالحظات‬ Installation Of Flood /‫تثبيت الكشاف‬
No Yes
Safety of ‫سالمة نقاط توصيل الكابالت‬
3 Comments / ‫مالحظات‬
Power Supply Points/
No Yes
4 Comments / ‫مالحظات‬ Earth Cable/‫التأريض‬

5 No Yes
....................................................................................................................................................................................................................... : Comment / ‫مالحظات حول الرافعة‬
Signature / ‫توقيعه‬ Electrician / ‫فني الكهرباء‬
Signature / ‫توقيعه‬ Electricity Engineer/ ‫مسؤول قسم االكهرباء‬
( / / ):: (Exclusion Date( in case the crane excluded, please reason for exclusion ) / / : ‫( تاريخ اإلستبعاد‬ ‫في حال إستبعاد الرافعة الرجاء ذكر سبب اإلستبعاد‬
............................................................................................................................................................................................................................................................
Safety ‫مدير السالمة‬ Safety ‫مهندس السالمة المسؤول‬

Construction Manager / ‫المدير التنفيذي‬
Manager / Engineer /

‫‪ELECTRIC WIRE INSPECTION‬‬
‫اسم المعدة‬ ‫أسالك الكهرباء – ‪Electric Wire‬‬

‫قدرة الكشاف‬ ‫تاريخ الفحص‬
‫اإلحداثيات‬ ‫رقم الكشاف‬
‫مالحظات‬ ‫األرضي‬
‫‪1‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫‪3‬‬ ‫مالحظات‬ ‫سالمة الفيش الكهربي‬
‫‪2‬‬ ‫‪2‬‬
‫‪1‬‬ ‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫سالمة األسالك‬
‫‪3‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫مالئمة حمولة السلك للمعدة‬
‫‪4‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫مالئمة طول السلك للعمل‬
‫‪5‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫‪4‬‬ ‫مالحظات‬ ‫حماية السلك‬
‫‪6‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫سالمة لوحة الكهرباء‬
‫‪5‬‬ ‫‪7‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫عدم وجود تحميل زائد‬
‫‪8‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫‪6‬‬ ‫مالحظات‬ ‫سالمة نقاط التوصيل‬
‫‪9‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫وضع السلك آمن بالنسبة للمارة أو‬
‫المعدات‬ ‫‪10‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات حول اسالك الكهرباء‪......................................................................................................................................................................................................................... :‬‬
‫مسؤول قسم االكهرباء‬ ‫فني الكهرباء‬
‫توقيعه‬ ‫المستلم ‪:‬‬ ‫‪2018‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫بتاريخ ‪:‬‬ ‫استالم المكتب الفني‬
‫‪( /‬‬ ‫‪/‬‬ ‫) ‪):: (Exclusion Date( in case the crane excluded, please reason for exclusion‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫( تاريخ اإلستبعاد ‪:‬‬ ‫في حال إستبعاد الرافعة الرجاء ذكر سبب اإلستبعاد‬
‫‪............................................................................................................................................................................................................................................................‬‬
‫‪Archive Received Date:‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫إستالم األرشيف بتاريخ ‪:‬‬

TOWER LIGHTS INSPECTION
Date Modified:
EQ. Name : ‫اسم المعدة‬ Tower Lights – )‫) أبراج اإلنارة‬

SN Date Of Inspection/ ‫تاريخ الفحص‬
Capacity/‫قدرة الكشاف‬ T. Light No. / ‫رقم البرج‬

TUV Exp. ( TUV) ‫تاريخ إنتهاء‬
/ ‫فتحات التهوية وخروج األدخنة سليمة‬

/ ‫ مالحظات‬Comments
Exhaust tube 1
No Yes
/ ‫ مالحظات‬Comments Earthing / ‫وجود تأريض برج اإلنارة‬
2
No Yes
Undamaged ‫كشافات اإلضاءة سليمة‬
lamp / 3
No Yes
/ ‫ مالحظات‬Comments Fixed boom /‫الذراع محكمة التثبيت‬
4
No Yes
Good internal ‫لوحة الكهرباء الداخلية جيدة‬
control panel / 5
No Yes
/ ‫ مالحظات‬Comments Fixed outrigger /‫األرجل محكمة التثبيت‬
6
No Yes
Undamaged control ‫أزرار التحكم سليمة‬
button / 7
No Yes
/ ‫ مالحظات‬Comments Good battery /‫البطارية جيدة‬
8
No Yes
Generator ‫الغطاء الخارجى للمولد مثبت‬
covered / 9
No Yes
Diesel tank ‫خزان الديزل حالته جيدة‬
good condition / 10
No Yes
/ ‫ مالحظات‬Comments Safety Tiers /‫سالمة اإلطارات‬
11
No Yes
No diesel ‫عدم وجود تسريب ديزل‬
leakage / 12
No Yes
/ ‫ مالحظات‬Comments No oil leakage /‫عدم وجود تسريب زيت‬
13
No Yes
................................................................................................................................................................................................... : Comment / ‫مالحظات حول الرافعة‬

Signature / ‫توقيعه‬ Technical / ‫فني المعدات‬

( / / ):: (Exclusion Date( in case the crane excluded, please reason for exclusion ) / / : ‫في حال إستبعاد الرافعة الرجاء ذكر سبب اإلستبعاد ( تاريخ اإلستبعاد‬
.............................................................................................................................................................................................................................................

OFFICES MAINTENANCE
Date Modified:
Offices Maintenance / ‫صيانة المكاتب‬

‫التاريخ‬ ‫القسم‬ ‫الشركة‬ ‫عدد األفراد‬ ‫مسئول المكتب‬ ‫رقم المكتب‬ ‫المنطقة‬
UNSAFED SAFE ‫البند‬ ‫الرقم‬

Main Electricity Panel ‫لوحة الكهرباء الخارجية‬ 1

Internal Electricity Panel ‫لوحة الكهرباء الداخلية‬ 2
Ensure the safety of the load capacity ‫التأكد من سالمة قدرة التحمل للوحة الداخلية‬ 3
Ensure the safety of the load capacity for (AC) ‫التأكد من سالمة قدرة التحمل للمكيف‬ 4
AC Switch ‫مفتاح التكييف‬ 5
AC Cable ‫توصيالت التكييف‬ 6
Lighting Switch ‫مفتاح اإلضاءة‬ 7
Ensure the integrity of the interior lighting ‫التأكد من سالمة اإلضاءة الداخلية‬ 8
Electric Socket ‫مقبس الكهرباء‬ 9
Extension Cord ‫توصيلة كهرباء‬ 10
Plastic Trunk (Duct) ‫حماية الكابالت الكهربائية‬ 11
Direct Connection (Without Male Socket) )‫توصيل مباشر (توصيالت غير نظامية‬ 12
Wire Electric computer ‫توصيالت أجهزة الكمبيوتر‬ 13
Electric Heaters ‫سخانات كهربائية‬ 14
Water Cooler ‫برادة ماء‬ 15
Refrigerator ‫ثالجة‬ 16
Ensure that there are no harmful devices ‫التأكد من عدم وجود أجهزة كهربائية مضرة بسالمة المكاتب‬ 17
Ensure that there are no Transformer ‫التأكد من عدم وجود أجهزة تنظيم التيار الكهربائي‬ 18
Ensure that there are earth ‫التأكد من وجود تأريض‬ 19
Recommendation / ‫توصيات‬ Observations / ‫مالحظات‬
Reported by / ‫ُمعد من قبل‬

‫مسؤل التكيفات‬ ‫مهندس الكهرباء‬ ‫فني الكهرباء‬ ‫مشرف السالمة‬ ‫القسم‬
‫اإلسم‬
‫التوقيع‬
. ‫كد من فحص جميع أجزاء المكتب وتم التوقيع عليه من قبل التنفيذ والتأكد من سالمته‬
. ‫حص بشكل عيني من قبل قسم السالمة وفحص متخصص من قبل قسم الكهرباء‬

WALK THROUGH
Date Modified:
Safety Walk Through Form ‫تقرير الجوالت التفتيشية‬

‫األعضاء‬ : ‫تاريخ الجولة‬
‫نهاية التنفيذ‬
‫بداية التنفيذ‬
‫االجراء‬ ‫السبب‬
‫تاريخ انتهاء المخالفة المحتملة‬ ‫نتيجة التقييم‬ ‫المسئول عن التنفيذ‬ ‫وصف المخالفة‬
‫التصحيحي‬ ‫الجذرى‬

‫‪SAFETY CHECKLIST FOR SAFETY HARNESS‬‬
‫اسم المعدة‬ ‫فحص حزام السالمة‬

‫‪S. N‬‬ ‫أقصي وزن يتحمله الحزام‬
‫الشركة المصنعة‬ ‫تاريخ الفحص‬

‫مالحظات‬ ‫أشرطة ربط األكتاف‬
‫‪1‬‬
‫‪8‬‬ ‫‪No‬‬ ‫‪Yes‬‬

‫‪1‬‬ ‫مالحظات‬ ‫أشرطة ربط منطقة الصدر‬
‫‪2‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫حلقات الربط الجانبية‬
‫‪6‬‬ ‫‪3‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫‪2‬‬
‫مالحظات‬ ‫حزام الوسط‬
‫‪4‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫‪3‬‬ ‫مالحظات‬ ‫أشرطة ربط منطقة األرجل‬
‫‪9‬‬ ‫‪5‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫أشرطة ربط منطقة الظهر‬
‫‪6‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫‪4‬‬
‫مالحظات‬ ‫ماصة الصدمات‬
‫‪7‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫حلقة التعليق الرئيسية‬
‫‪8‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫خطافات التعلق‬
‫‪9‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫‪5‬‬ ‫‪7‬‬ ‫مالحظات‬ ‫ملصق المعلومات‬
‫‪10‬‬
‫‪11‬‬ ‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫حبل التعلق‬ ‫‪11‬‬
‫‪12‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات‬ ‫حلقة ربط حبل التعلق‬
‫‪12‬‬
‫‪No‬‬ ‫‪Yes‬‬
‫مالحظات حول حزام السالمة ‪.......................................................................................................................................................................................................................:‬‬
‫بتاريخ ‪:‬‬
‫توقيعه‬ ‫المستلم ‪:‬‬ ‫استالم المكتب الفني‬
‫‪20‬‬ ‫‪/‬‬ ‫‪/‬‬
‫‪( /‬‬ ‫‪/‬‬ ‫) ‪):: (Exclusion Date( in case the crane excluded, please reason for exclusion‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫( تاريخ اإلستبعاد ‪:‬‬ ‫في حال إستبعاد الرافعة الرجاء ذكر سبب اإلستبعاد‬
‫‪............................................................................................................................................................................................................................................................‬‬
‫‪Archive Received Date:‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫إستالم األرشيف بتاريخ ‪:‬‬

‫‪FIELD TOURS‬‬
‫نموذج ‪ /‬الجولة الميدانية‬

‫التاريخ‬ ‫المهندس‬
‫منطقة العمل‬
‫الموضوع ‪/‬‬
‫المالحظات‬ ‫غير مطابق‬ ‫ال‬ ‫نعم‬ ‫البند‬

‫الجميع داخل موقع العمل يرتدون مهمات الوقاية الشخصية المناسبة لعمله‬
‫هل تم التأكد من إعطاء جميع العاملين المحاضرات المناسبة لطبيعة عمله‬
‫هل تم عمل تدابير الرقابة األمنة في أماكن العمل‬
‫توافر جميع اإلحتياطات الالزمة لسالمة من بالموقع‬
‫سالمة مداخل ومخارج موقع العمل‬
‫االتأكد من تأمين وغلق جميع الفتحات فوق سطح العمل‬
‫اإلضاءة هل هي مناسبة لبيئة العمل‬
‫هل يوجد أي أخطار كهربائية‬
‫المخاطرالكيميائية – هل يتم تقييمها وحفظها في أماكن أمنه‬
‫المعدات هل هي سليمة ومستوفية أوراق الفحص‬
‫الضوضاء – اإلهتزازهل يتم التحكم بهم‬
‫هل يوجد إسعافات أولية متاحة بمنطقة العمل‬
‫هل جميع من بموقع العمل على دراية بتعليمات السالمة وطرق اإلخالء الطارئة‬
‫التأكد من نظافة الموقع‬
‫اإلجراء المتخذ ‪/‬‬
‫التوقيع‬ ‫التاريخ‬ ‫مدير المشروع ‪ /‬مهندس التنفيذ‬

HAND TOOL CHECKLIST ‫فحص المعدات اليدوية‬
Date Modified:
‫فحص المعدات اليدوية‬

Inspection items must be marked “OK” if in good condition, “X” if damaged

‫( يجب وضع عالمة‬OK) ‫( إذا كانت املعدة بحالة جيدة او عالمة‬X)‫فى حالة التلف او غير مطابقة ملعايير السالمة‬
Items marked “X” may not be used and must be removed from site.
‫( ال يجب استخدام اى معدة تحمل عالمة‬X) ‫ويجب ازالتها من املوقع نهائيا‬
Condition of the
DESCRIPTION OF EQUIPMENT ‫وصف المعدة‬ SI
equipment
Label ‫ملصق‬
Date ‫التاريخ‬
(Hammers, chisels, screwdrivers etc..)‫الرقم التسلسلى ) المطارق واألزاميل والمفكات وغيرها‬ ‫حالة المعدة‬
‫ ال‬/ ‫نعم‬
INSPECTOR’S SIGNATURE:
‫توقيع مفتش السالمة‬

HAND TOOL DEFECTS
SI DESCRIPTION OF DESCRIPTION OF DEFECT DATE CORRECTED
‫الرقم التسلسلى‬ EQUIPMENT‫وصف المعدة‬ ‫ عدم التتطابق‬/‫وصف العيب‬ ‫تاريخ التصحيح‬
INSPECTOR’S SIGNATURE:
‫توقيع مفتش السالمة‬

MONTHLY AUDIT FOR DELIVERABLES
Date Modified:
MONTHLY AUDIT FOR DELIVERABLES

SCORE REMARKS
1 MANAGEMENT/SUPERVISION MAXIMUM
ACTUAL SCORE PERCENTAGE
POSSIBLE
The Health and Safety Manual is available and
approved, and includes provisions for

1
identifying and controlling all hazards expected
on the all sites.
A Health and Safety policy by the Contractor
relevant to this site is updated in writing,
2
approved and signed and displayed &
communicated with all work force
Health and Safety targets and objectives are in
3 place, tracked and reviewed at planned
intervals
There is evidence that site supervision has a
personal commitment to safety execellence (e.g
4
supervision has frequent positive interactions
with site workers)
Possible Points Awarded
2 ROLES AND RESPONSIBILITIES
Health & Safety responsibilities and
accountabilities are defined and documented
1
for all levels while recognising that everyone
has responsibilities related to Health & safety
Management demonstrates leadership in safety
2 processes and routinely participates in safety
meetings and safety inspections
Management demonstrates commitment to
3 continual improvement of the Health & Safety
performance
3 HAZARD IDENTIFICATION AND RISK ASSESSMENT
There is a current and active Risk Register in
1
place
There is evidence the Risk Register is being
used effectively to proactively manage the
2
hazards and controls being developed and
tracked
There is evidence the top hazards from the site
3 Risk Register have been communicated to
appropriate site personnel
The hierarchy of control for hazard mitigation
4
is followed
There is a system to track Risk Register
5
controls in a timely fashion
There is a change management process in place
that identifies possible additional hazards,
6
evaluate the risk and implements controls
before introducing the changes
There is evidence that Task Safety Analysis
7 (TSA)/Job Hazard Analysis (JHA) or equivalent
are being developed
Risk Assessments are conducted prior to
8 commencing any non routine task and
becoming a mindset
4 COMMUNICATION AND COORDINATION

Leading and lagging Safety Indicators are
1
posted in a prominent place
Regular meetings are held with the Client
2 Representative and Contractors /
SubContractors to discuss Health & Safety.
Toolbox Talks/Meetings are conducted on a
3
daily basis
5 RECORDKEEPING AND DOCUMENT CONTROL
Procedure (s) are in place for controlling all
1
documents related to the site H&S
Lagging H&S statistics (including injury
2 statistics) are tabulated and utilized to identify
positive/negative trends
Injury and illness record keeping is maintained
3
on site
An incident report is on file for each recorded
4
injury or illness
Chemical Management and records related to
5 storage, disposal, waste generator activities are
properly maintained
Records are legible, easily accessible and
6
maintained in good condition
6 HEALTH AND SAFETY INSPECTIONS
Inspections are conducted as per a pre-
1
determined schedule
The system includes methods to ensure closure
2
of corrective actions in a timely manner
There is documented evidence that
3 management is regularly involved in the
inspections
7 CORRECTIVE AND PREVENTIVE ACTIONS
Records of employee H&S related discipline are
1 maintained (e.g verbal/written warning,
retraining or termination)
There is a corrective action plan and follow up
2
process to prevent recurrence of incidents
A documented action plan from previous audits
3
is available
8 INCIDENT MANAGEMENT
There is a written Incident Investigation and

1
Reporting procedure
2 There a record for incidents.
Imminent dangers (unsafe acts and conditions)
3
are correctly reported and addressed
All high potential Incidents are investigated
4
with formal root cause analysis
Management is proactive in post-incident
5
follow up
A lessons learnt process is implemented at the
6
site
9 PTW
Is there a system for permits to work in
1
operation?
Have operators and Supervision been trained
2 in the Permit to Work procedures?
Are work areas checked prior to cancellation
3 of permit?
Are there arrangements in place to audit the
4 Permit to Work procedures?
Are PTW issued & cancelled by authorized
5 permit issuer and receivers?
Is there any register maintained for all Permit
6 to Works issued?
7 Are all general and specific risks and

precautions addressed?
8 Is all work activities covered under PTW?
9 Are PTW supported by Risk assessment and
MS?
10 Are permit records trackable?
Are permit record kept for at least 1 year for
11 routine activities and 5 years for non-routine
activities and available?
10 CONTRACTOR MANAGEMENT
Safety evaluations are conducted during bid
1
evaluation stage
Contractors are managed appropriately to
2
reduce the number of repeat occurences
Contractor H&S plans and programs are
3
submitted and reviewed prior to mobilization
Contractor H&S violations are documented and
4
required corrective actions are performed
11 POSITIVE INCENTIVE
There is a formalized Positive Incentive
1
Program in place
There is evidence that site is using the program
2
to reinforce specific behaviours
12 PERFORMANCE INDICATORS
1 Audit Documents are readily available.
Method statement for specific activity were
2 followed and implemented during job
execution.
13 WORKING AT HEIGHT,LIFELINE
All fall protection equipment is under a
1
documented inspection program
All fall protection equipment is inspected prior
2
to use & maintained their record.
Hazards from adjacent activities, travelling
3
cranes etc have been mitigated
The lifeline and anchorage system has been
designed and approved by a competent person
4 or is obious to the auditor the anchor point is
sound and meet the requirement of
withstanding 18kN
The designer of the system approved the
5 number of workers who will be using it (max
weight)
Lifeline is used as per its Manufacturer
6
specifications.
Horizontal lifelines have been installed as per
7
drawings
Fall arrest should be the last option used for
safe work at height. Have all options been
8 properly assessed? E.g. guardrails, elevated
platform and scaffolds (elevated platforms are
fully decked, guard rail & toe board provided)
Workers wear appropriate fall protection
9 equipment where required and know
appropriate anchorage points for
All fall protection equipment is under a
10
documented inspection program.
Safety hard hat chain straps are worn when
11
working at heights.
All fall protection equipment is inspected prior
12
to use & maintained their record.
Hazards from adjacent activities, travelling
13
cranes etc. have been mitigated.
Personnel are protected from falling out
14
openings.
Personnel below are protected from falling

15
materials (e.g. tools, bolts…)
Exclusion zones for all overhead work are
16
sufficient to protect workers below.
Floor opening are properly guarded or are
17
covered with a secured cover.
Permit to Work system in place and followed
18
when working at heights.
All workers can move from one station to
19 another or access to work area vertically
without exposure to a fall.
The lanyard length is as short as necessary and
20
in no case greater than 1.8m
Lanyards should have a shock-absorbing
21
feature to limit the arresting forces.
Fall equipment is free of potential damage from
22
welding, chemical corrosion or sandblasts.
Free-fall distance been considered and all free
23
fall clearances been checked.
Anchorage points for body harnesses are
24 located at shoulder heights and overhand for
self-retracting lifelines where possible.
25 Tie off is achieved at all times 100%
14 LIFE LINE
The lifeline, lanyard, or self-retracting lifeline is
1 properly attached to an adequate anchorage
point.
The lifeline is protected from abrasive or
2 cutting edges and ropes or cables are free from
signs or wear or abrasion.
3 Life is used as per its specifications.

The lifeline and anchorage system has been
designed and approved by a competent person
4 or is obvious to the auditor the anchor point is
sound and meet the requirement of
withstanding 18 KN.
The designer of the system approved the
5 number of workers who will be using it (max
weight)
Horizontal lifelines have been installed as per
6
drawings.
15 RESCUE PLANNING
A rescue plan for fallen workers has been

1
implemented
The rescue plan has been well communicated
2 to all responsible persons and they are aware
of their role in the rescue plan
The rescue plan has sufficient resources for

3
immediate implementation
16 ELEVATED WORK PLATFORMS (EWP)

1 Valid TPC for equipment & operator is avaliable
Employees have been trained on specific model
2
being used
3 Operation manual is avaliable
Daily inspections are being conducted and
4
recorded
5 Trained ground persons with EWP as required
Workers are using only manufacturers
6
approved anchor points
All warning levels and stickers are clearly
7
visible and legible is
17 LADDERS, SCAFFOLD
1 Ladders are inspected & are in good condition

Extension ladders are secured top and bottom
2
and placed at the correct angle.
Rails extend at least 1 meter above landing or
3
work platform.
Defective ladders are tagged and removed from
4
the work area.

Three point of contact rule is used on ladders,
5
work is not performed from ladder.
Metal ladders are not used where contact with
6
electrical energy is possible.
7 Fixed ladder landing areas are general clear.
8 Step ladders are fully extended when in use.
18 LIFTING OPERATIONS
Lifting operations are prepared and executed
1 in accordance with existing procedures and
industry standards
There is a system for ensuring personnel

2
competency for lifting operations (i.e. Training)
A competent person supervises all lifting
3
operations
Responsibilities and authority of personnel
involved in lifting operations are clearly
4
defined including documented checks of
equipment
There is a documented lift plan in place for
5
routine and non-routine lifting operations
Appropriate and accurate lifting
6 documentation is readily available and referred
to throughout the lift process.
The lifting plan for critical lifts is
7
communicated to all personnel involved.
There is a coordination meeting participated in
8 by site management before critical lifting &
recorded.
There is adequate effective communication
9 throughout the lift between operator &
certified rigger- verbal and non – verbal.
10 There is process for post lift review, if required.
There is a documented lift plan in place for
11
routine and non routine lifting operations
Appropriate and accurate lifting
12 documentation is readily available and referred
to throughout the lift process
19 CRANE AND RIGGING
Lifting equipment operators are informed of

limits of approach distances and / or that
1
energized systems have been isolated / de-
energized.
And anti-two-block limit switch is in place and

2
functional on all cranes

Operational Manual is available (Arabic &
3
English)
Locations of overhead and underground
4 utilities are identified, marked and protected as
required.
Load weights are known and communicated to
the Operator (Rated load capacities and
5
operating instructions are available to crane
operators)
Lifting equipment is inspected and certified
6
prior to arrival / use on site.
Lifting equipment inspections are performed
7
by a qualified person and documented.
Ground conditions are evaluated and

8 confirmed acceptable for placement and
support of lifting equipment if required.
Overhead or underground utilities are isolated
9
/ de-energized as required.
Rigging equipment is inspected and maintained
10
and free of damage, excess wear or defect.
Regular inspections or rigging equipment are
11 performed and the equipment is tagged
accordingly.
Critical lift plans are reviewed and approved by
12 competent person / supervisor prior to
performing the lifts.
All required load and range charts are posted,
13
legible, current and utilized.
Adequate protection is in place to ensure
14 personnel don’t enter within swing radius of
the crane or load.
The crane is operated level with the
15 appropriate outrigger placement (deployed
and locked) and adequate outrigger pads.
Proper signals are used when raising, lowering,
16
and swinging the hook, loaded or unloaded.
Load weight indicator devices are in place and
17 functional on lifting equipment as required by
prevailing legislation.
18 Outriggers are fully extended when in use.
Load capacity at lifting radius is not being
19
exceeded
Operator’s pre-use inspection checklist has
20
been completed.
All crane and sling hooks are equipped with a
21
functional safety latch.
Work area has been properly barricaded and
22
posted to warn employees of work activity.

Lifting equipment and lifting tackles are
23
certified from 3rd party
Proper lifting gears has been used & checked
24
prior to each use by certified rigger.
20 SUSPENDED BASKETS
Suspended work baskets are certified as safe
1
and utilized for personnel as required
Suspended work baskets are built according to
2
approved designs
A load test has been performed that established
3 a safety factor of 2 times for the suspended

work basket
Suspended work baskets are labeled as
required to show maximum weight capacity,
4
maximum number of persons allowed and the
total basket weight
When work baskets are in use an anti-two
5
block device is always installed and functional.

21 GENERAL EQUIPMENT
Operator are qualified and competent for his
job (HEPTC requirements) Trained to operate
1
his specific equipment. Original SAG license
available with the operators.
Equipment used is specifically designed for
2 that job and is operated within the safety limits
as per the design.
Valid inspection sticker with inspector Name /
3 Signature available on all equipment and
equipment were in good condition.
Operator certification program was utilized for
4
aerial lifts, heavy equipment and vehicles.
5 Seat belts were provided and used.
6 All lights are operational.
7 Horns are operational.
8 Back-up alarms are operational.
Guards around pinch points were available as
9
per manufactures recommendations.
Flashing lights and / or strobes were used on
10
all slow moving vehicles.
Pneumatic / hydraulic hose maintain and
11
connections properly secured.
Elevated roads were protected by beams and /
12
or guard rails.

Haulage roads were maintained in good
13
condition.
Necessary blinking lights were provided to
14
warn operators during night work activities.
No oil and other liquid leaking in the
15
equipment.
Refueling maintenance activities were
16 performed taking care of static electricity and
away from traffic areas.
Pedestrian access was separated from
17
equipment and vehicles.
Daily equipment inspection is carried out and
18 the operator understands the checklist
elements.
Equipment were maintained and met all safety
requirements; Preventive maintenance were
19
done to all mobile and heavy equipment with
available documentation.
20 Operator SAG & Consultant.
21 Overall Conditions
22 Fire Extinguisher
22 CONCRETE, CONCRETE FORMS, SHORING, MASONRY
All shoring erected to contain and / or support
1 concrete was the required type and approved
installation procedures were followed
23 TOOLS
All power tools are formally inspected on a
1
scheduled basis and tagged.
24 ELECTRICAL SAFETY
1 Lock out Tag out System in use
2 Correct voltage
3 Portable Generators condition
4 3 Wire Ground Cord and 3 Prong Ground Plug
5 Proper Usage of receptacles / Plug
6 Electrical Panel Condition
7 Acceptable overhead power clearance.
8 Proper Related Cords and condition
9 Ground fault Circuit Interrupter (GFCI)
Energized Power Equipment Label & Danger
10
Sign
11 Appropriate Barriers and Lights

Circuit Label, Number and Diagram & Power
12
Panel
Cord repairs are performed by a qualified
13
person
Worn, Frayed or spliced cords / cables are
14
removed.
Electrical equipment is marked with the
15
amount of voltage
GFCIs controlled outlets and panels are labeled
16
and tested.
Electrical cords are inspected and approved for
17 the type of usage and are free of breaks in the
insulation.
Outlets, receptacles, junction boxes etc. are in
18
place as required
Electrical cords are elevated over passage ways
19 or are protected from damage when crossing
roads or passage ways.
All temporary electrical outlets, receptacles,
20 junction boxes, and panels are electrically
grounded.
Working spaces, walkways, and similar
21
locations are kept clear of appliance cords
25 CONFINED SPACE ENTRIES

Entry permits are used, and sign-off for
1
responsible parties is provided and followed.
Additional permit is required as per work need
2
(like hot work) in the confined space.
Hazards are identified and controlled before
3 conducting confined space work (i.e. electrical,
mechanical and chemical)
Confined spaces have been identified, marked
4
and protected from unauthorized entry.
5 A confined space entry procedure is in place.
Adequate atmospheric testing is being
6 performed prior to entry and monitored at
frequent intervals thereafter.
Required emergency equipment is available
7 (e.g. tripod, body harness, S.C.B.A, Fire
extinguisher etc.)
A qualified person has conducted a hazard
assessment of the confined space and
8
documented the hazards, risk level and
mitigation controls.
Air quality test records are maintained and
9
available.
A rescue plan for confined space entries is
10
available.

Application workers are trained in the confined
11
space rescue plan
Air test equipment is bump tested daily or as
12 prescribed by prevailing legislation and
manufacturer’s specifications.
Rescue workers are trained in confined space
entry, emergency response, PPE including
13
respiratory protective equipment (i.e. SCABA),
First Aid and CPR
Adequate measures been taken to prevent
14 hazardous materials from entering the
confined spaces.
An attendant (watch person) is present at all
15 times during a confined space entry &
maintained the log.

Communications is maintained at all time with
16
attendants.
Affected confined spaces are purged
17
appropriately and monitored.
26 GENERAL AND LIGHT VEHICLES

Seat belts are available, in good working
1
condition and used by drivers.
Mobile phones are not used while the vehicles
2
/ equipment are in use.
Vehicles with poor visibility, oversized loads,
operating in limited area and other high risk
3
situations are moved with the assistance of
signal person (flagman)
A preventive maintenance program is in place
4
and maintenance record exists
Drivers / operators have driving license from
5
the Government / 3rd Party
Only authorized vehicles and equipment are
6
allowed on the road / site.
Speed limits are posted and vehicles /
7
equipment are operated at a safe travel speed.
Speed limits are posted and vehicles /
8
equipment are operated at a safe travel speed.
Elevated roads are protected by berms and / or
9
guard rails.
Reflective triangles and fire extinguishers are
10
provided for all equipment as required.
11 Back up alarms are operational
When operators leave their equipment, the
12 hydraulics are lowered and the machine is
turned off
Daily inspection by operator is done & record
13
of checklist is maintained.

27 TRAFFIC CONTROL
Site has traffic control plan in place including a
1
parking back in policy
Traffic control plan is being utilized and proper
2
authorities are notified.
Adequate signage in place, correct to standard
3
and visible.
Jersey barriers and other barrications are
4
properly in place.
Work zones have sufficient spacing from
5
hazards (separated from traffic)
Signage and traffic flow designated to minimize

interaction with the public and when necessary
6
clearly marked and / or controlled by flag
persons
7 Flag man (with PPE / Flag, Vest & Equip.)
8 Night Lights
28 FIRE PREVENTION
Fire suppression systems are inspected on a
1
regular basis
Fire Extinguishers are provided as required
2 (e.g. where flammable and combustible
material is stored or used)
Portable storage tanks containing liquid
3 flammables are located at least 6 meters (20
Ft.) away from building.
There are written guidelines on how to report
4
and what to do in case of fire.
5 Access to Fire Extinguishers is unobstructed.
6 Fire Extinguishers are identified as required.
Monthly and annual inspections are conducted
7
and documented.
Materials that react to water are not stored
8
with flammables.
9 “No Smoking” signs are posted appropriately
“No Smoking” and other restrictions on sources
10
of ignition are complied with
Oxygen and acetylene tanks / cylinders (full
11
and empty) are segregated.
Smoke detectors are provided at all offices,
12
closed stores and are tested on a regular basis.
13 Fire Hydrants / Hose / Nozzle / Wrench

14 Emergency Telephone Number Posted
15 Smoke Detectors in Fire Alarm Place.
29 HOT WORK
Hot work is performed under a safe work or
1
hot work permit
A Fire Watch is in place for hot work when
2
required.
A Fire Extinguisher is immediately available
3
and operable at all Hot Work locations
Screens, shields or eye protection is provided
4 and used to protect workers from welding
hazards)
Arc Welding is performed with a required
5
electrical ground
Machines are turned off at end of shift or when
6
not in use
Welding cables and ground cables are free of
7
damage and inspected.
8 Compressed gas cylinders are labeled
Compressed gas cylinders are secured in
9
upright position, stored and capped.
Reverse flow or flash back arrestors are used
10 on all oxygen / acetylene rigs or built into
torch.
Regular gauges are attached as required and in
11
good condition.
Compressed gas cylinders valves are turned off
12
when not in use for extended periods of time.
Hot slag and sparks are maintained and
13
controlled & use fire blanket where required.
Required PPE is worn for the hot work activity
being performed or where immediate exposure
14
occurs, including eye protection, clothing,
gloves, and respirator if needed.
Oxygen / acetylene hoses are maintained free
15
of oil and grease.
Oxygen and fuel gas cylinders (full and empty)
16
are segregated.
All line or hose connections have a positive
17 means of coupling to prevent uncoupling while
in use.
Empty cylinders will be stored separately form
18 full cylinders with their valves in the closed
position
30 DE-ENERGIZATION
The procedure that clearly outline methods to
1 be applied for the control of hazardous energy
is avalaible

Procedures have been developed, documented,
2 and implemented for the control of hazardous
energy
All energy-isolating devices are operated only
3 by authorized persons or under the direct
supervision of an authorized person
Special precautions and procedures are
4 available and implemented when isolations
cover one or more shift changeovers
31 LINE BREAKS
A walk down of the line/equipment was
1
performed with site personnel

2 Work is being performed under a work permit
32 EMERGENCY PREPAREDNESS
The approved Emergency Response Plan (ERP)
1 is specific to the site and adequately addresses
all potential emergency scenarios
The ERP includes a method of accounting for all
2
employees after an emergency occurs
The ERP is documented and posted/available
3
on site
Emergency Preparedness Coordinator or
4
similar position appointed to respond.
Employees have a working knowledge of
5 Emergency/Evacauation Procedures, Escape
Routes and the Emergency Notification Process
Emergency Drills are conducted at least twice
6
per year as per approved procedure
There are written and implemented
procedures for dealing with letter bombs,
7
written threats, telephone bomb threats and
for dealing with suspicious packages
The Emergecny Evacuation Plan has been
8
communicated to the local authorities
Pre planning for local natural disasters include
written procedures and includes assigned
9
responsibilities for executing local disaster
plans
Emergency lighting, power, radios and rescue
10
equipment are available
Emergency evacuation signs or exit signs are
11
posted
12 The ERP has been communicated to all affected

33 First Aid/Medical Response
Medical response personnel are trained and
1
certified in First Aid, CPR and AED
2 Well – equipped ambulance is available.
A specific first aid medical response plan is
3
available.
Procedures are in place to accompany any
4 injured employee to doctor / emergency room,
notify supervisor and family members.
Clear direction exists on who to call if there is a
5 medical emergency with clear structure of
responsibilities
Medical response kits and required First Aid
6
station and supplies are available.
Medications of any kind are only dispensed be
7
medical staff
The medical treatment facility is maintained in
8
a clean and sanitary condition.
Members of the Emergency Response team

9
have training in CPR and fire extinguishers use.
34 SECURITY
There is a written security plan for the site and
1
it has been implemented.
The security plan includes all the standard
2 elements (e.g Access Control, Employee ID,
stickers for vehicles & equipments etc)
On going security assessments are conducted
3
and reviewed
35 HAZARDOUS MATERIAL COMMUNICATION
Emergency procedure is available and workers
1 know what to do in case of an emergency with
hazardous materials.
MSDS for controlled / hazardous products are
2 available and employees have access and
familiar controls
Hazardous materials have been stored in
3
approved containers.
Storage containers of controlled / hazardous
4
products have labels in place.
Decanted / empty containers of controlled /
5
hazardous products have labels in place.

Hazardous waste generated on site is stored,
6
identified and removed regularly
Emergency eye wash is provided near
7
hazardous material storage.
Chemical resistant clothing worn by employees
8 meets the level of protection specified in the
work permit
9 Designated substances (Asbestos, Lead etc.)
Proper PPE is provided to employees with
10
potential exposures.
Exposure control procedures including
11 provision for respiratory protection are in
place.
There are procedures for disposal of
12 designated substances including asbestos
containing material
There are procedures for handling asbestos
13
and lead
14 Housekeeping and General Site Conditions.
All work areas including floors, working
15 surfaces, walkways and passenger ways are
clean and free of trash and debris.
Offices / storage rooms and areas are orderly
16
and maintained
Trash receptacles are provided in all work
17
areas & are disposed regularly & properly.
Scrap lumber is free of protruding nails or
18
other puncture hazards
19 Caps on exposed rebar ends provided
Cigarette butt cans, where used, are maintained
20 free of combustible material and empties
routinely – Can it be used in our Project?
Sufficient lighting is provided for the work
21
being performed
22 Approved procedure for Handling Chemicals
23 Separate Chemical Storage
24 Segregate Storage
Chemical Hazard Bulletin (CHB) /
25 Manufacturer Safety Data Sheet (MSDS)
available at Storage Facility.
26 Warning Signs (Arabic & English)
27 Area Fenced / Locked
28 Containers Labeled
29 Emergency Procedures

30 Scott Air Pak
31 Shower / Eye Wash
32 Personal Protective Equipment (PPE)
33 First Aid & Extinguisher
34 Ventilation
Safe Transferring of Chemicals between
35
containers
36 DESIGNATED SUBSTANCES (ASBESTOS, LEAD ETC)

Exposure control procedures including

1 provision for respiratory protection are in
place
There are procedures for disposal of
2 designated substances including asbestos
containing material
There are procedures for handling asbestos
3
and lead
37 RADIATION
Non destructive testing is planned and
1
communicated
Emergency plan for foreseeable radiation
2
incidents is in place
38 HOUSEKEEPING AND GENERAL SITE CONDITIONS
All work areas including floors, working
1 surfaces, walkways and passengerways are
clean and free of trash and debris
Offices/storage rooms and areas are orderly
2
and maintained
Trash receptacles are provided in all work
3
areas & are disposed regularly & properly
Cigarette butt cans, where used, are maintained
4 free of combustible material and empties
routinely- Can it be used in our Project?
Sufficient lighting is provided for the work
5
being performed
39 HEALTH AND HYGIENE
Adequate number of toilets and hand washing
1
facilities are provided and kept sanitary?
2 Pest control is provided as required

Health risks are assessed, including exposure
3 to hazardous material, biohazards, noise and
designated substances such as asbestos
4 Occupational Hygiene test records are available
Insect borne infectious disease (malaria etc…)

5 control programs are applicable and
implemented as required
Ventilation in work areas is provided for the
6
type of work being performed
There are designated areas where employees
can eat meals and take breaks in a sanitary
7
environment separate from any toilet facility
and not exposed to toxic materials.

Potable drinking water is provided, kept clean
8
and individual cups are provided
Protection against sunburn is provided (shade,
9
sun block cream, training, etc.)
For (food) or beverages are not permitted in
10
operating areas and none were observed
11 Material handling and storage
All materials are maintained in a safe and
12
stable manner
13 Chemicals are stored in approved containers
Material handling equipment is used to handle
14
/ move material when possible
15 No smoking signs
16 Designated smoking / break areas / butts tray
17 Trash containers with lids
18 Drinking water and disposable cups
19 Trash bin with lid

40 TRAINING
All new / employees are provided health &
1 safety orientation and it is documented before
going to site.
Safety induction covers all the project
2
requirements
3 Training matrix is available
4 Training matrix covers all project requirements
Training record as per training matrix is
5
available

Refresh training program is available &
6
maintained.
7 Training evaluation record is available
Record of cover up as per evaluation record is
8
available if any.
9 Tool box talk record is available
10 Supervisory leadership training is in place.
Competency of key workers is assessed based
11
on education, training or experience
H & S Tool box talks / meeting are conducted in
12 all relevant languages and loud enough for all
attendees to hear
Employees who work as flagmen or provide
13
hand signals have received training
Employees have been trained on how to
14
operate a Fire Extinguisher
Employees have received training on heat
15
stress
Workers received training to ensure they
16 understand their roles and responsibilities in
the event of an emergency.
41 HOUSEKEEPING AND GENERAL

Project work areas were cleaned, free of excess
1 trash, Combustible materials, debris or other
waste materials
All Walkways, passageways, access, and egress
2
are free from obstructions and safe
All Material or equipment properly were stored
3 in the designated area with proper barricading
and sign boards.
All Electrical cords, hoses, welding leads, etc
4 elevated and well managed to prevent trip
hazards.
All Work area were free of protruding nails or
5 any other puncture hazards; all Rebar caps
installed and maintained
Waste materials are kept inside the trash
6 receptacles that is provided in work areas and
water stations.
Stationary fuel driven equipment have drip
7
trays to contain oil spills.
8 Spilled liquids were cleaned immediately
Materials on warehouse shelving and other

9
storage area was stored safely and neatly.
Concrete and other debris were not
accumulated, have the proper designated
10
washing area (with sign board, barricade and
no scattered concrete waste)
Form works, Woods, and Planks are stacked
after proper de-nailing; De-nailing done in a
11
designated area with proper signs and
barricading
Signs were provided to encourage
12
housekeeping
Offices/clinics were clean and trash removed
13
daily
Elevated areas were maintained clear of debris,
14
material, tools, etc.
15 Dust control were done in all area.
General housekeeping was acceptable all
16 around the site and offices free from all type of
trip, slip and fall hazards.
17 Caps on exposed rebar ends provided

42 MATERIAL HANDLING
All materials are maintained in a safe and
1
stable manner
2 Chemicals are stored in approved containers
Material handling equipment is used to

3
handle/move material when possible
43 HEALTH, HYGIENE & WORKERS WELFARE

The required number of toilets were provided
1
(1 toilet for every 50 workers)
Toilets were kept clean (inside and outside,)
2
and sanitary toilet paper is in place
Mess hall with proper food storage facility and
hand washing facilities were available for
3
workers. (Food intake only inside the mess
hall)
Vermin (rodents, insects, etc) control was
4 provided to avoid insect infestation and
sickness outbreak.
Local exhaust ventilation was used where
5
necessary
Required number of proper drinking water
6 stations are available on site; Enough iced
drinking water was provided at all the times

Ventilation in work areas is provided for the
7
type of work being performed
There are designated areas where employees
can eat meals and take breaks in a sanitary
8
environment separate from any toilet facility
and not exposed to toxic materials
Potable drinking water is provided, kept clean
9
and individual cups are provided
Protection against sunburn is provided (shade,
10
sun block cream, training, etc)
Food or beverages are not permitted in

11
operating areas and none were observed
44 SMOKING SHELTER
Smoking Shelter were provided and maintain

1
in safe condition
Smoking shelters is in Safe location under any
2
circumstances.
Smoking shelters is enough to accommodate
the number of workers with in the vicinity or
3
Contractor should set up a rule not to over flow
the number of smoker in one shelter.
Isolate (smoking shelter) and away from
4 structure, equipment, machines, and building
(at least 6 meters).
No presence of combustible material around
5
the smoking shelter.
Smoking shelter is made of non combustible
6
material.
7 Smoking Shelter Sign board is posted.

Electric safe lighter or safe matches is available
8
inside smoking shelter.
Fire Extinguisher, water bucket, and sand
9
bucket is available.
10 Proper ash tray is available inside the shelter.
Garbage Bin or trash bin is away from the

11
smoking shelter.
45 HEAT STRESS SHELTER
Contractor has developed updated Heat Stress

1
Prevention plan with shelter requirements.

Proper / sufficient Heat Stress Shelters are
2 provided to accommodate the number of
employee.
Heat Stress Shelter is positioned in safe
3
location.
Heat Stress Shelter is big enough to
4
accommodate intended Employees.
Heat Stress Shelter is not exposed to work
5
related hazards. (Shall be PPE free area).
Heat Stress Shelter is strong, rigid and good
6 enough to protect employees from dust and
extreme weather conditions.
No noise or other disturbances for the
7
occupants
8 Heat Stress Shelter is maintained hygienic
Proper functioning Industrial cooling fan is
9
provided for the Heat Stress Shelter.
Drinking water is available near to the Heat
10
Stress Shelter at all time.
11 Heat Stress Shelter is not used for smoking.
Heat Stress Shelter have adequate sign boards,
12
emergency numbers and awareness posters.
Contractor has inspection programs for Heat
13
Stress Shelter
Safe access is provided towards the Heat Stress
14
Shelter.
No other hygienic and health hazards present
15
in the field and office.
46 NIGHT WORK AND LIGHTINGS
Required lighting was provided for all the work
areas, HSE department have the monitoring
1
system to ensure adequate lighting were
provided during night activities.
Portable light plants were maintained and kept
2 operational; Cable wire were rolled after use;
and kept in safe place during day time.
47 HAZARD COMMUNICATION PROGRAM

MSDS for all Hazardous Chemical / Materials
1
were available on site, storage area, and clinic
Vessels & material containers were labeled as
2
required
Flashing light were installed in the road
3
barricade, excavation barricade and etc)

Hazardous areas are properly barricaded,
Hazard information posters / signs were
displayed to inform employees regarding the
4
specific hazards in the site (e.g. Chemical
storage, confined space, falling hazards,
excavation, lifting is going on, & etc)
Hazards in a location were discussed in the
toolbox meeting / discussion and the worker is
5 aware & know the precautions of the obvious
hazard in the location or the condition of their
work.
Hazardous material has been stored in
6
approved containers.
Decanted/empty containers of
7 controlled/hazardous products have labels in
place
Hazardous waste generated on site is stored,
8
identified and removed regularly
Emergency eye wash is provided near
9
hazardous material storage
Chemical resistant clothing worn by employees
10 meets the level of protection specified in the
work permit
48 PERSONAL PROTECTIVE EQUIPMENT (PPE)
Eye protection worn where required, Head

protection worn where required, Protective
1
foot wear worn by all employees, Face shields
were worn when required
Noise areas were posted and hearing
2
protection was worn
Hand protection was provided and used that
3 were selected according to specific hazards,
anticipated or present.
Reflective vest were provided and use by
4
stand-by men, riggers and flagmen
PPE's were maintained in acceptable safe
5
condition, not altered / modified and properly.
Extra PPE's are available in the store room for
6
unscheduled replacement and for the visitor.
The workers know and understand the
7 important of his PPE for the specific hazards of
his jobs.
Other task required specific PPE were worn.
8 (Sand blasting, spray painting, dealing with
hazardous chemicals, etc)

Proper PPE is provided to employees with
9
potential exposures
49 HAND TOOLS AND POWER TOOLS

Correct tools were used properly for the
1
specific job performed.
Tools were carried, maintained and stored
2
properly
Chisels, hammer wrenches and other "striking
3 tools" were dressed at the striking end to
prevent "mushrooming"
Job made / home made tools / improvised tools
4
were prohibited and none were observed
All power tools & hand tools were inspected
5
on a regular basis and tagged or color coded.
6 Required safety guards equipped and used
Wheels on bench and stand grinders were
7
dressed as required
Portable power tools must be equipped with
8
properly functioning dead man switch
Discs on portable grinders were compatible
9
with the equipment's maximum RPM
Are all portable, electrically powered tools
properly grounded and with reliable power
10
cable protected by GFCI / ELCB or double
insulated?
The person using the tools / power tools
11
knows the hazards and the precautions.
Generally all tools were maintained and in safe
12
condition
13 Power tools are double insulated
All tools are visually inspected prior to use and
14
defective ones tagged out of service
Correct hand tools are used for the work being
15
performed
16 Tools are carried and stored properly
Powder tools loads are removed while the tool
17 is stored or left unattended - Cartrdiges are
properly disposed off
50 MACHINE SAFETY
Machine guards are in place and functional to
1 prevent worker’s hands, arms, or other body
parts from making contact with moving parts.

All moving parts, including gears, sprockets,
2 pulleys, flywheels, belts and chain drives are
guarded as required.
No evidence exists to suggest guards have been
3
modified.
Fail-to-safe / dead man switches are installed
4 on rotating equipment and power hand tools
and are operational.
Equipment has an easily accessible emergency
5
stop button where applicable.
6 Machines are properly grounded.
7 Electrical cords or connectors in good shape.

51 HOT WORK
Hot work performed with a hot work permit
1
(The checklist in the permit to be filled up)
Trained and competent Fire watch was
2 assigned with fire extinguisher and know
regarding emergency measures
Is there ANY flammable or combustible
3 substance evident in the material on which
HOT WORK is being performed?
Containment of hot work and welding screens
4
as required
Arc welding was performed with a required
5
electrical ground
Compressed gas cylinders were stored
(protected from external heat sources such as
6 flame impingement, intense radiant heat,
electric arcs, or high-temperature lines)and
capped as required.
Reverse flow or flash back arrestors were used
7
on all oxygen/acetylene set and the torch side.
Regulator gauges were attached as required
8
and in good condition
9 Acetylene pressure not exceeds 15 PSI.
10 Strikers were used to light torches.
11 Welding rods were stored as required
Compressed gas cylinders were located outside
12 of closed areas and were not exposed to slag or
sparks.
Gas cylinders were moved and
transported(prevent them from creating a
13
hazard by tipping, falling, or rolling) in the
required manner.
Oxygen / acetylene hoses were maintained free
14
of oil and grease
15 All cylinders were labeled as required
Workers doing hot work / Welders understand
the hazards and the precautionary measures
16
including PPE and emergency plan of hot work
activities
All other hot works activities and equipments
17 requirements met the standards.(without any
other issues)
A Fire Extinguisher is immediately available
18
and operable at all Hot Work locations
Screens, shields or eye protection is provided
19 and used to protect workers from welding
hazards).
Machines are turned off at end of shift or when
20
not in use
Welding cables and ground cables are free of
21
damage and inspected
22 Compressed gas cylinders are labelled
Compressed gas cylinders are secured in
23
upright position, stored and capped
Compressed gas cylinders valves are turned off
24
when not in use for extended periods of time
Oxygen and fuel gas cylinders (full and empty)
25
are segregated
All line or hose connections have a positive
26 means of coupling to prevent uncoupling while
in use.
Empty cylinders will be stored separately from
27 full cylinders with their valves in the closed
position
52 ELECTRICAL
Electrical equipment was marked as to the
1
amount of voltage and the control source
The required "lock out - tag out " procedure
2
was implemented where required.
All line parts were guarded or protected
3
against contact
All electrical lines and outlets were protected
4
with GFCI / ELCB.(Effectively Grounded)
Identified with label Outlets, receptacles,
5 junction boxes, etc, and were maintained as
required.
Where electrical cords were suspended or
6 secured, they were done so by using non-
conducting materials
Electrical cords condition is acceptable, all are
7
inspected and color coded.
Light bulbs and fluorescent tubes were
8
guarded as required
Generally the site was free from all type of
9
electrical hazards.
Cord repairs are performed by a qualified
10
person
Worn, frayed or spliced cords/ cables are
11
removed
Electrical equipment is marked with the
12
amount of voltage
Electrical cords are inspected and are free of
13
breaks in the insulation.
Outlets, receptacles, junction boxes etc are in
14
place as required
All temporary electrical outlets, receptacles,

15 junction boxes, and panels are electrically
grounded.
Suitable firefighting equipment available in
16
ready position.
53 EQUIPMENT OPERATIONS/ CRANE OPERATION

1
job. Trained to operate his specific crane.
Rigger are qualified and competent for his job
2 .The rigger was trained and certified for the
specific load being lifted
Crane / recertification / inspections were
3 performed (annual, monthly and daily
inspections are carried out).
The swing radius of the counter weight was
4 barricaded and signs posted. No person will
stand inside the barricade.
Safe distance maintained from dangerous
5
edges;
Load monitoring indicators(LMI) were
6
available and utilized
An anti-two-block and safety latch is in place
7
and functional
Lifting tackles were inspected and color coded,
8
not left on the ground
The load capacity of each rigging device
9 including the hook block was known by label,
and documents
Tag line were used to control the suspended
10
load
Softeners were used to protect wire and nylon
11
chokers where needed

Tools, Tackles, water kegs and other materials
12
are not stored on the crane.
No Toolbox / Storage box on near any pinch
13
point of the crane
Preventive maintenance were done to all
14
cranes with available documentation
The lifting plan for critical lifts is
15
communicated to all personnel involved
There is a coordination meeting participated in
16 by site management before critical lifting &
recorded
There is adequate effective communication
17 throughout the lift between opertor & certified

rigger- verbal and non-verbal
18 There is process for post lift review, if required
Lifting equipment operators are informed of
limits of approach distances and/or that
19
energized systems have been isolated/de-
energized
Operational manual is avaliable (Arabic &
20
English)
Locations of overhead and underground
21 utilities are identified, marked and protected as
required
Load weights are known and communicated to
the Operator (Rated load capacities and
22
operating instructions are available to crane
operators)
Rigging equipment is inspected and maintained
23
and free of damage, excess wear or defect
24 competent person/supervisor prior to
performing the lifts.
All required load and range charts are posted,
25
legible, current and utilized
Adequate protection is in place to ensure
26 personnel don't enter within swing radius of
the crane or load
The crane is operated level with the
27 appropriate outrigger placement (deployed
and locked) and adequate outrigger pads
Proper signals are used when raising, lowering,
28
and swinging the hook, loaded or unloaded
Load capacity at lifting radius is not being
29
exceeded
All crane and sling hooks are equipped with a
30
functional safety latch

54 TOWER CRANE OPERATIONS

Signal man / Rigger is certified from approved
1
3rd party.
Signal man / Rigger is equipped with
2
communication device.
3 Rigger are qualified and competent for his job.
4 Pictures are posted in the equipment.
5 Know and understand signaling.

Operator already undergone for medical
6
assessment.
Signal man / Rigger is equipped with all
7 required the PPE and Safety gears needed for
lifting operation.
Operators and riggers understand the
8
significance of their job.
Operator understand the safety warning stated
9
in the manufactures Manual.
10 Operator understand simple English.
11 The operator has Third Party certificate
Operator know and Understand the hazards of
12
the equipment and make immediate response.
13 Operator Know the safe proximity Distance
Signal man / Rigger do not walk or stand
14
beneath the load.
Signal man / Rigger Know where to position
15
himself
Under no circumstance to allow people to stay
16
in hazardous Zone.
Use their equipment according to its specific
17
designed.
Signal man / Rigger controls the movement of
18
load and has the capability to use his authority.
Operator manual was available and Load charts
19
were posted and utilized.
20 Maintain regular contact with each other.
Tower crane is commissioned under
21
manufacturer supervision.
22 Tower crane is 3rd party certified.

Tower is being maintained regularly as per
manufacturer manual. Local rules will
23
supercede manufacturer requirements if not
less than manufacturer requirements.
Tower crane working radius is maintained
24
secured.
Does tower crane has over lap with any other

25 crane. If Yes, what additional preventive
measures have been taken to avoid collision?
Tower crane foundation is approved by
26
consultant.
Additional riggers are assigned as required
27
depending upon the location (different levels)?
Tower cranes are placed in free swing mode
28
when operator is not in the cabin?
Tower crane has safe access and egress for
29
operator.
Tag lines of sufficeint length are used to control
30
waving of load.
31 Rigging equipment is certified by 3rd party.
Rigger equipment is inspection and color coded

32
as per monthly color coding system.
33
competent person prior to performing the lifts.
Rigger level 1 / Competent person supervise
34
critical lift.
Proper lifting gears are being used & checked
35
prior to each use by certified rigger.
55 FLAMMABLE DELIVERY TANKER
1 The condition of the vehicle?

Equipment used for the intended purpose of
2
the manufacturer?
3 Operated within capacity?
Hose, piping, and fittings for tanks are in good
4
condition?
Provided with a rear bumper to protect the
5 tank and piping in the event of a rear-end
collision?
Tanks and containers marked with the name of
6 the product they contain and "FLAMMABLE-
KEEP AWAY." "No Smoking" signage?

Metal warning plate not subject to corrosion
7 located in a noticeable place permanently
affixed to the tank or tank frame?
8 MSDS of the cargo available?
9 Vents for Cargo Tanks available?
Fire extinguishers available and kept in good
10
operating condition?
Grouding and Bonding arrangements available
11
with the truck?
56
GENERAL EQUIPMENT

job. Trained to operate his specific equipment.
1
Original SAG license available with the
operators.
Equipment used is specifically designed for
2 that job and is operated within the safety limits
as per the design.
Valid inspection sticker with inspector
3 Name/signature available on all equipments
and equipments were in good condition.
Operator certification program was utilized for
4
aerial lifts, heavy equipments and vehicles.
5 Seat belts were provided and used.
6 All lights are operational.

7 Horns are operational.
8 Back-up alarms are operational.
Guards around pinch points were available as

9
per manufactures recommendations.
Flashing lights and/or strobes were used on all
10
slow moving vehicles.
Pneumatic / hydraulic hose maintain and

11
connections properly secured.
Elevated roads were protected by beams
12
and/or guard rails.
Necessary blinking lights were provided to
14
warn operators during night work activities .
No oil and other liquid leaking in the
15
equipment.
Refueling / maintenance activities were
16 performed taking care of static electricity and
away from traffic areas.
Pedestrian access was separated from
17
equipments and vehicles.
Daily equipment inspection is carried out and
18 the operator understands the checklist
elements.
Equipments were maintained and met all

safety requirements; Preventive maintenance
19
were done to all mobile and heavy equipments
with available documentation.
57 GENERAL AND LIGHT VEHICLES

Seat belts are available, in good working

1
condition and used by drivers.
Mobile phones are not used while the
2
vehicles/equipment are in use.
Vehicles with poor visibility, oversized loads,
operating in limited area and other high risk
3
situations are moved with the assistance of
signal person (flagman).
Only authorised vehicles and equipment are
4
allowed on the road/site.
Speed limits are posted and
5 vehicles/equipment are operated at a safe
travel speed.
Elevated roads are protected by beams and/or
6
guard rails.
Reflective triangles and fire extinguishers are
7
provided for all equipment as required.
8 Back up alarms are operational.
When operators leave their equipment, the
9 hydraulics are lowered and the machine is
turned off.
58 HAULING
1 Dust control is implemented where required.

Flashing lights are used on all slow moving
2
vehicles.
Refueling and maintenance activities are
3 performed away from haulage road traffic
areas
4 Roads are maintained in good condition
Blind corners / intersections are identified and
5
signage is posted.

59 SUSPENDED WORK BASKETS OPERATIONS
Suspended work baskets were certified (safety

1 factor of 2 times) as safe and utilized for
personnel as required.
Suspended work baskets were labeled as
required to show maximum weight capacity,
2
maximum number of persons allowed and total
basket weight (actual empty weight).
Does the responsible person know the
3 maximum capacity and the safe usage of the
Basket.
4 Auxiliary life line was installed and used.

Man basket were maintain in safe condition
5 and periodic inspection done. Competent to
operate.
Permits were utilized and retained for
6
suspended work basket usage.
When work baskets are in use an anti-two
7
block device is always installed and functional.
60 RESPIRATORY PROTECTION
Fit testing was provided for all employees

1
required to wear respirators.
Respirators used were selected according to
2
the hazard present.
Breathing air compressor have a proper
3
filtration system.
Breathing air compressor have a carbon-
4
monoxide alarm.
Breathing air compressor have a reserve air
5
tank.
Breathing air compressor have a compressor
6
failure alarm.
Hose couplings that were incompatible with
7
other couplings.
The air quality from the breathing air
8
compressor was periodically sampled.
Breathing air cylinders were labeled as
9
required.
The quantity of air available in breathing air
10 cylinders was monitored to assure there was
sufficient air to exit the area.

61 EXCAVATION AND TRENCHING

Required excavation permits were utilized
1
properly.
Spoil soil or other material were stored at least
2
1 meter from the edge.
Correct sloping / shoring / sheet piling /
3 benching were maintained according to the
type of soil.
Proper and adequate access and egress are
4
available.
Physical barricades, warning signs, and flashing

5
lights were provided.
All excavation were maintain in safe condition
6
and inspected by competent person.
62 STEEL ERECTION AND FLOOR AND WALL OPENING
1 Required safe access and egress provided.
Wall and floor openings were guarded or

2
covered as required.
Elevated areas are free of loose excess
3 materials and debris that could fall to levels
below
4 Bolt-up requirements were met.

Temporary platform were available as
5
required.
Barricades and signs were posted in the area to
6 warn employees as required (Lifting on
progress available).
All other safety equipments in steel erection
7
were met.
63 FALL PROTECTION
Body Harness required and worm in proper

1
manner.
Lanyard are adequately secured to stable
2
anchorage.
Fall protection equipment is used for its
3 purpose, well maintained, periodically
inspected. (Including PPE).

Hand railing system were installed on uneven
4
ground, foundation, bridge, ramp, stair, and etc.
Open holes are protected with strong cover,

5
railing system, .
The worker knows and understand the
6 hazards, precaution, and suitable protection
required is implemented.
Fall arrest should be the last option used for

safe work at height. Have all options been
7 properly assessed? E.g guardrails, elevated
platform and scaffolds (Elevated platforms are
fully decked, guard rail & toe borad provided).

Workers wear appropriate fall protection
8 equipment where required and know
appropriate anchorage points for.
Safety hard hat chain straps are worn when

9
working at heights.
Personnel are protected from falling out
10
openings .
Personnel below are protected from falling
11
materials (e.g tools, bolts,….).
Exclusion zones for all overhead work are
12
sufficient to protect workers below.
Permit to Work system in place and followed

13
when working at heights.
All workers can move from one station to
14 another or access the work area vertically
without exposure to a fall.
The lanyard length is as short as necessary and
15
in no case greater than 1.8m.
Lanyards should have a shock-absorbing

16
feature to limit the arresting forces.
Fall equipment is free of potential damage from
17
welding, chemical corrosion or sandblasts.
Free-fall distance been considered and all free

18
fall clearances been checked .
Anchorage points for body harnesses are

19 located at shoulder height and overhead for
self-retracting lifelines where possible.
20 100% Tie off is achieved at all times ???

64 LIFELINE
The lifeline, lanyard, or self-retracting lifeline is
1 properly attached to an adequate anchorage
point.
The lifeline is protected from abrasive or
2 cutting edges and ropes or cables are free from
signs of wear or abrasion.
65 FALL ARRESTORS
The fall arrester is compatible with the lifeline

1
on which it is to be installed or operated.
Fall arresters are in operational condition and

2
regularly inspected.
Fall arresters are equipped with a locking
3 mechanism that prevents unintentional
opening of the device.
Fall Arrester's "up" direction is marked
4
properly.
66 LADDERS, SCAFFOLDS, AND ELEVATED WORK PLATFORMS
1 Ladders were in good condition.

Secured in an approved manner and placed at
2
the correct angle.
Exceed the landing area by 1 meter or have a
3
grab rail.
Rope grab was provided more than 9 meter
4
continuous climb vertical ladder.
Other safety requirements for ladders were
5
met.
Extension ladders are secured top and bottom
6
and placed at the correct angle.
Rails extend at least 1meter above landing or
7
work platform.
Defective ladders are tagged and removed from
8
the work area.
Three point of contact rule is used on ladders,
9
work is not performed from ladder.
Metal ladders are not used where contact with
10
electrical energy is possible.
11 Fixed ladder landing areas are general clear.

12 Step ladders are fully extended when in use.

67 SCAFFOLDS
Scaffold tags are used to identify incomplete

1
scaffolds and requirements for safe use.
Scaffolding is inspected every 7 days and

2
Scaffold-tag is displayed and up to date
All scaffolding components are fit for purpose
3
(no omission)
4 Scaffolding is erected on sound footings.
Scaffolds are free of defects and built per

5
specifications
Employees who erect and dismantle scaffolds
6
are qualified and competent.
A competent person inspects all scaffolds and
7 maintains a current and complete record or
those inspections.
Access ladder / staircase is adequately
8
provided
Scaffolds have the required top, mid guardrails
9
and toe boards in place.
Wind speeds are monitored and personnel
10 removed from outdoor scaffolds during high
winds.
When material is stacked or grouped on a
scaffolding, the weight of the material is
11
demonstrated to be within the capacity of the
scaffold and planks
Complete scaffold decking is provided
12 whenever possible and is of scaffold grade
material.
Area below is controlled and / or barricaded
13
when working overhead.
14 Plumb and Level
15 Proper Couplers
16 Base, Sole Plates and Screw Jacks Condition
68 TWO-POINT SUSPENSION SCAFFOLDS WERE ERECTED IN AN APPROVED MANNER
1 Approved design.
2 Approved life lines were provided.
3 Approved rope grab lanyards provided.

Scaffold tags are used to identify incomplete
4
scaffolds and requirements for safe use.
Scaffolding is inspected every 7 days and Scaff-

5
tag is displayed and up to date.
All scaffolding components are fit for

6
purpose(no omission).
7 Scaffolding is erected on sound footings.
Scaffolds are free of defects and built per

8
specifications.
Access ladder/ staircase is adequately
9
provided.
Scaffolds have the required top , mid guardrails
10
and toe boards in place.
When material is stacked or grouped on a
scaffolding, the weight of the material is
11
demonstrated to be within the capacity of the
scaffold and planks.
Complete scaffold decking is provided
12 whenever possible and is of scaffold grade
material.
Area below is controlled and/or barricaded
13
when working overhead.
69 ELEVATED WORK PLATFORMS (HIGH-JACKERS, SCISSORS LIFTS ETC)
1 A means of tie-off was provided and used.

Elevated work platforms were used in
2 accordance with manufacturers
recommendations.
3 Outriggers provided and used as required.
4 Ground controls operational.
5 Operators trained and certified.

Employees maintain both feet on the platform,
6 and do not use equipment as a means of access
/egress, and do not work from guard rails.
Workers are using only manufacturers
7
approved anchor points.
All warning levels and stickers are clearly
8
visible and legible Is.

1 Required access and egress provided.
Masonry saws were guarded with a
2
semicircular enclosure cover.
All shoring erected to contain and / or support
installation procedures were followed.
Precast and lift slab operations were
4 performed in accordance with respective
standards.
PPE required for these operations was
5 provided and used which would include safety
glasses, gloves, proper clothing and foot wear.
All connections on air hoses and pipes were

6 secured to prevent displacement (whip
arrestor of boom hose)
There is a hose cover of the concrete pump
7
boom while moving the boom to other location.
There is a designated concrete mixer washing

8 area with signed board, barricade, flagman
assigned, and tire stopper / chock.
9 General safety requirements were met.
71 PORTABLE CABIN & STEEL CONTAINERS - GENERAL
Portable cabins on site are initially inspected

1
by Electrical engineers and civil engineers.
Periodic inspection programs are placed by a

2
qualified electrician.
3 Adequate escape facilities are maintained.
Carpets, rubber or plastic mats and floor are in

4
good condition.
File cabinets and storage shelves are secured to
5
prevent tripping over.
6 Office equipments are in operable condition.
7 Handrails for steps and stairs.
8 Trash bins availability and clean up.
Chemicals, flammable liquids or compressed

9
gases are not stored inside the office.
Adequate passage ways between furniture’s
10
and equipments.

Portable machines and temporary devices are
11
properly positioned and secured.
Interior doors are labeled as to function of the
12
room.
Personnel hand tools purpose receptacles are
125 volt single phase 15-20 and 30 ampere and
13
protected with Ground Fault Circuit
Interrupter.
72 LAYOUT
Layout plans are approved from Project senior

1
management.
Layout are approved from affiliate IS&E and
2
Fire Department.
Two directional accesses are maintained for
3
firefighting purpose.
Walkways are maintained in buildings not less
4
than 3.7 foot.
73 EMERGENCY PLAN
Building emergency evacuation plans are

1
placed.
Building emergency plan updating is
2 conducted. (if any condition changes in
buildings).
Building emergency exit and routes are clearly
3
visible.
Safe assembly points/ muster points are clearly
4
identified.
5 Two emergency exit routes are available.
Emergency egresses from all parts of buildings
6
are maintained and unobstructed.
Separation of exit have one hour fire resistance
7
rate.
Width of access is sufficient to accommodate
8
the maximum permitted occupant.
Exit doors openings from inside without any
9
special knowledge.
Exits are clearly marked with sign and signs lit
10
are 54lux.
Building emergency plans are available for
11
employees review.

74 FIRE PROTECTION
Class A: B: C fire extinguishers are available at

1
32 feet travel distance.
Fire protection manual inspection within 30
2
days intervals.
Recorded the fire protection inspections and
3
register are available.
Inspection tags on fire extinguishers and
4
inspections are logged on tags.
Smoke detectors are installed and in operable

5
condition.
6 Smoke detector locations.
Battery powered smoke detectors log for
7 battery changing’s maintained. (battery
replacement within 30 days)
Function test on detectors are conducted and
8
documented.
No Smoking signs are posted on building
9
entrance and other locations.
Smoking shelters are provided and proper
10
distance is maintained from building.
Fire Extinguishers are provided as required
11 (e.g where flammable and combustible
material is stored or used).
Portable storage tanks containing liquid
12 flammables are located at least 6 meters (20 ft)
away from buildings.
13 Access to Fire Extinguishers is unobstructed.
14 Fire Extinguishers are identified as required.

Materials that react to water are not stored
15
with flammables.
16 "No Smoking" signs are posted appropriately .
"No smoking" and other restrictions on sources
17
of ignition are complied with.
Oxygen and acetylene tanks/cylinders (full and
18
empty) are segregated.
75 FIRE ALARM
1 Employee’s fire alarm systems are installed.

Manual fire alarm system activation boxes are
2
provided within 200 feet distance.
Fire alarm boxes access are maintained
3
without any obstruction.
4 Fire watcher is available in buildings.
76 ILLUMINATION
Lighting in work areas is comfortable. General

750 lux, Drafting room 800-1000 lux, Corridors
1
750 lux, Stairways 750 Lux, Wash rooms 130-
150 lux Conference room 300 lux.
Emergency lights are provided for not less than

2
one and half hours.
Emergency lights initial illumination not less
3
than 11 lux.
4 Repeated automatic type emergency lights.
5 Emergency light inspection logs and registers.
Functional test conducted 30 days intervals

6
and not less than 30 seconds.
77 ELECTRICAL
1 Power cable insulation and conduit or buried.
Telephone and computer data cables are

2
routed.
Lighting circuit wirings are coded and “UL”
3
marked.
Extension cords are not use as permanent
4
connections.
Re-locatable extension power cords are “UL”
5
listed types.
Plugs and connectors are no exposed current
6
carry parts or single insulated parts on outside.
Re-locatable extension power cords are
7
directly to a permanent installed receptacle.
Re-locatable extension power cords routes are
8
not under floors or floor covering/ carpets.
Re-locatable extension power cords are
9 polarized or grounded type with over current
protected.
Cable conditions, no splices, deterioration or
10
damage.

Feeders are protected against over current
11
protection.
12 Over current device access maintainability.
Main disconnection panels and access

13
maintainability.
Protective device capability of detecting and
14
interrupting.
15 Non combustible shields for switchboards.
No openings on electrical boxes, panel boards
16
and cabinets.
Panel boards are marked by manufacturer with

17
voltage and the current rating.
18 Panel board circuits are identified.
19 Circuit breakers are marked for ampere rating.
20 Outlet voltage is clearly indicated.
Weather proof receptacle at outdoors and wet

21
locations.
All electrical cables routed in Electrical Metallic
22
Tubing (EMT) .
78 GROUNDING
All portable cabins are grounded at two points

1
with No.2AWG copper wires.
Path of grounding are permanent and
2
continuous.
Panel boards and other electrical appliances
3
are grounded.
79 SERVER ROOM
1 Daily monitoring of cooling systems are placed.
2 Proper ventilation distance is maintained.
80 DE-ENERGIZATION
If live work is being performed, the

1
requirements of international standards ???
There are provisions in place to verify the
2
effectiveness of the lock-out/tag-out system.
All locks are identified with the name/picture
3
of person locking out.
Lock-out and tag-out devices are removed by
4
the lock owner ???
Outside servicing personnel is informed of the
5 lock-out and tag-out procedures before
equipment is erviced.
Work areas are inspected before re-energizing
6
equipment.
There are strict provisions in place for
7 removing locks when lock owner is not
available.
81 LINE BREAKS
Isolation points have been identified and

1
locked and tagged out.
Barricades and signs are posted in the area to
2
warn employees as required.
82 CONFINED SPACES
Lighting and electrical tools used inside
1 confined spaces were 24 volt or GFCI
protected.
Required emergency equipment was available
2
(i.e. body harness, SCBA, fire extinguisher, etc).
3 Gas Testing carried out periodically and logged.

Entry permits, which meets requirements were
4 used, and sign-off for responsible parties was
provided and adhered to
Warning sign (no permit no entry) was posted
5
on the entrance.
Workers working inside confined space
6 understand the hazards and precautionary
measure of confine space.
Stand-by person/s ("Hole Watch") were
7 knowledgeable of confined space and
procedures.
All other requirements for confined space were
8
met the standards.
Confined spaces have been identified, marked
9
and protected from unauthorized entry.

Adequate measures been taken to prevent
10 hazardous materials from entering the
confined spaces.
An attendant (watch person) is present at all
11 times during a confined space entry &
maintained the log.
Communications is maintained at all time with
12
attendants.
Affected confined spaces are purged
13
appropriately and monitored.

83 ROAD AND TRANSPORTATION SAFETY
1 Availability of pedestrian walk ways.
Designated parking areas marked in each

2
Contractor, safe for any vehicle and workers.
Vehicle and Equipment movement on site are

3
safe for workers.
"Sponsor of load" letter used for transporting
4
wide and long materials.
Adequate signage in place, correct to standard
5
and visible.
Jersey barriers and other barrications are
6
properly in place.
Work zones have sufficient spacing from
7
hazards (separated from traffic).
Signage and traffic flow designed to minimize
interaction with the public and when necessary
8
clearly marked and/or controlled by flag
persons.
84 ADDITIONS FROM PROCEDURE AND HSE MEETINGS

All supervisor / foreman in charge in the site
are qualified and competent. (understand the
1
Permits, and Hazards identification and
rectification.)
Supervision is present during the work
2
activities.
Employee ID badges/helmet sticker/certificate
3 card/color coded according to the training
received.
Sign board at each work location with
4
supervisory information.

Spray painting and blasting safety
5
requirements were met.
Each work location with assembly point and
6
emergency contact numbers.
85 QUESTIONS TO WORKERS
1 Today's toolbox topic
Orientation given or not - what you remember

2
(language).
Awareness regarding emergency evacuation /
3
assembly area.
86 IMMINENT DANGER EXAMPLES
1 Material could be dislodged.
2 without a valid permit.
3 Failure to use Permit Specified PPE.
4 No 100% fall protection.

5 No hole covers.
6 No trench box.
7 Working on Red tagged/not inspected scaffold.
8 No energy lock out system.

Working electrical circuits with out approval or
9
PPE.
10 Excess lifting or no inspection.
11 Refueling without grounding .
12 Altering power tool.
Operating equipment with faulty safety

13
devices.
14 Welding sets without the flash back arrestors.
15 Pneumatic hoses without wipe lash arrester.
87 RADIATION

1 Each radiographer wears a dosimeter.
Barricades and warning signs for radiation

2
work is clear and communicated.
A radiation protection advisor/officer is
3
appointed.
88 TOOL BOX TALK
H & S Toolbox talks/meetings are conducted in

1 all relevant languages and loud enough for all
attendees to hear.
89 KITCHEN
Stove, candles and open hot plates are not in

1
use.
Warning signs and instructions for microwaves
2
use.
Ventilations for microwaves, refrigerators and
3
stabilizers.
4 Receptacle is nonconductive materials.
90 ABRASIVE BALSTING / SPRAY PAINTING
1 Trained operators Medical Certification
Operator / Helper Personal Protective

2
Equipment
3 Air Filter (Hood) / Pressure Gauge
4 Air Intakes Location (Compressor)

Equipment / Materials Properly Grounded /
5
Bonded
6 Barricades and Warning Signs in Place.
7 Compressor Alarms / Shutdown
8 Dead Man Controls
9 Hearing Protection
10 Hoses & Nozzle Fittings Security Fixed
11 Blast Cleaning Residue Proper Disposal
12 Proper Storage of Materials

13 Air Breathing Compressor
14 Nozzle Grounding
15 Blasting Agent (Grit)
91 TRENCHING / EXCAVATION, SHORING & EXPLOSIVES.

Shoring / Trench Box / Sloping / Benching /
1
Shielding
2 Proper cross Over Ramps

Spoil Clearance at least .6 meter (2 Ft.) from

3
the Edge of Excavated Area.
4 Barriers / Warning Signs / Lights
5 Access / Egress (Ladders)
6 Gas Test Work Permit.
7 Confined Space – 1.2 m (4 feet)
9 Combustion Engines Positioned Down wind
10 Standby man monitoring Entrance

11 Excavation plan
Approved by SAG for Handling & Use of
12
Explosives
13 Blasting Precautions near Existing Facilities
14 Approved Blasting Plan

92 OPERATORS SAG AND CONSULTANT CERTIFIACTION

1 Riggers Consultant Certification
2 Appropriate Rigger in use
3 Approved Critical Lift Plan on Site
4 Daily Pre-use Inspection Checklist
5 Crane Inspection Sticker Valid
6 Spreader Bean Inspection Sticker
7 Crane Stability and Positioning
8 Proper use of Outriggers / Fully Extended.

9 Outrigger Floating pads Compliance.
10 Safe load chart (Arabic & English)
11 Safety latches (Hooks)
12 Slings Inspection Log
13 Condition of Slings
14 Lattice / Boom Damage
15 Anti-Two Block Device (Except Side booms)
16 Tag Lines in Use

17 Spark Arrestors on Exhaust (In-Plant)
18 Load Moment Indicators (LMI)
19 Man Basket Inspection Sticker
20 Man Basket Overall Condition

Appropriate Dist. Form O/H Power lines &
21
Other
93 GAS / ELECTRICAL WELDING

1 Welder (PPE)
2 Fire Extinguisher Adequate.
3 Fire Watch Adequate
4 Shielding and Welding Curtains in Place.
5 Ventilation Adequate
Work area Flammable Materials Protected or
6
Removed.
7 Color coded acetylene or Oxygen hoses.
8 Gauges / Hoses Condition / Hose Clamps
9 Acetylene Pressure Below 15 PSIG

10 Gas Cylinders On / Off Wrench
11 Availability of Sticker
12 Protective Caps in Place on Gas cylinder.
13 Flash Back Arrestors

14 Anti-Flash Screens.
15 Welding Cable Condition (No Splices)

16 Electrode Holder / Ground Clamp Condition
17 Generators / Welding Mech., Overall Condition.
94 COMPRESSED GAS HANDLING

1 Cylinders Secured
2 Proper Storage (Shaded and Separated)
3 Protective Caps in Place.
4 Proper Handling
Proper Color Coding

Proper and Appropriate Cylinder Label
7
Attached.
8 Cylinder’s Permanent Stamped Markings
95 AIR COMPRESSORS
1 Pressure Relief Valve Operational
2 Air Pressure Gauges
3 Hose and Connection / Drains
4 Safety Whip checks to secure hoses
5 Coupling Safety Wired
6 Proper Guards
7 Fire Extinguisher
8 Proper Grounding
9 Personal Protective Equipment

10 Overall Condition

1 Required Access and egress provided.
Masonry saws were guarded with a
2
semicircular enclosure cover.
All Shoring erected to contain and / or support
installation procedures were followed.
Precast and lift slab operations were
4
performed in accordance with respective
standards
PPE required for these operations was

5 provided and used which would include safety
glasses, gloves, proper clothing and food wear.
All connections on air hoses and pipes were
6 secured to prevent displacement (whip
arrestor of boom hose)
There is a hose cover of the concrete pump
7
boom while moving the book to other location.
There is a designated concrete mixer washing
8 area with signed board, barricade, flagman
assigned, and tire stopper / chock.

9 General Safety Requirements were met.
10 Access Condition
11 Rebar Ties Bent Over / Capped as Appropriate.
12 Form work / Bracing

Experienced concrete Pump Operator and
13
Helper
14 Concrete Pump Truck Spotter.
97 TOOLS
1 All power tools are color coded
2 Power tools are double insulated
Job made / homemade tools are prohibited and
3
none were observed.
All tools are visually inspected prior to use and
4
defective ones tagged out or service.
Correct hand tools are used for the work being
5
performed
6 Tools are carried and stored properly
Power tools loads are removed while the tool is
7 stored or left unattended – Cartridges are
properly disposed off.
Discus on portable grinders / cutters are
8 compatible with the equipment’s maximum
revolutions per minute (RPM)
98 LAYDOWN / OFFICES, CAMP AND OPERATING FACILITIES

1 Smoke and fire detectors
2 Fence and Gate ( 2 Gates minimum)

3 Separation of dining and cooking
Spacing between buildings (intent. Building
4
Code) – 9 m.
5 Aisles – Fence to Bldgs. (15 ft.)
6 Fire Hose reel System
7 Assembly areas
8 Food storage
9 Electrical System and Generators

10 First Aid Station / Clinic / Ambulance
11 Trash Cans
12 General Cleanliness
13 Room occupancy
14 Pest and animal control
15 House keeping
16 Potable water system approval
17 Sanitary facilities
18 Laydown yard design and approved

19 Laydown spacing
20 Traffic / parking plan
21 Security / Guards etc.

GRAND TOTAL
PERCENTAGE OF COMPLIANCE
Prepared By Reviewed By Approved By


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SAFETY INSPECTION FORMS

HEALTH, SAFETY & ENVIRONMENT

Title Reference Rev. Pages

FIRE FIGHTING EQUIPMENT,EMERGENCY LIGHTING INSPECTION LOG SBG- HSE -010 8 3

‫مرفق نماذج الفحص و التفتيش الخاص ببرنامج السالمة ‪:‬‬

‫ونود التنويه علي ما يلي ‪:‬‬

‫‪SBG-HSE-CONSTRUCTION SAFETY INSPECTION CHECKLISTS‬‬ ‫‪ -1‬النموذج‬

‫توافرها باألنشطة المختلفة بالمشروع ‪.‬‬

‫وتقدير وتقييم مسئول السالمة بالمشروع للوضع على الطبيعة ‪.‬‬

‫‪Copyright Saudi Binladin Group‬‬

MONTHLY / WEEKLY SAFETY REPORT

MONTHLY SAFETY REPORT ‫تقرير احصائيات السالمة الشهري‬

1.4 No of Equipment at Site ‫عدد المعدات بالموقع‬

2. HEALTH SAFETY ‫الصحة و السالمة‬

2.1 Fatalities (FAT) ‫الوفيات‬

2.2 Lost Time Accident (LTA) ‫الوقت المهدر نتيجة الحوادث‬

2.3 Near Misses (NM) ‫الحوادث الوشيكه‬

2.4 Major Accident ‫اإلصابات الشديدة‬

2.5 Occupational Illness Cases ‫حاالت األمراض المهنية‬

2.6 Total Recordable Incidents (TRI) ‫إجمالى الحوادث المسجلة‬

2.7 First Aid Cases (FAC) ‫حاالت االسعافات االولية‬

2.8 Safety Violation Raised ‫معدل مخالفات السالمة‬

2.9 Fire Accident ‫حوادث حريق‬

2.10 Asset Damages (AD ( ‫إلخ‬.... - ‫التلفيات (للمعدات – المبانى‬

2.11 Road Traffic Accidents (RTA) ‫حوادث المرور‬

2.12 Termination ‫فصل من العمل‬

3. TRAINING AWARENESS ‫التدريب والتوعية‬

3.2 Safety induction ‫تعريف السالمة‬

3.3 Task Safety Analysis (TSA) Briefings ‫موجز تحليل السالمة‬

3.4 Safety Representatives Meetings ‫إجتماعات مندوبى السالمة‬

3.6 External Training Courses ‫دورات تدريبية خارجية‬

4. MONITOR & AUDIT ‫مراقبة و تدقيق‬

4.1 No of Internal Audits ‫تقارير المراجعة الداخلية‬

Copyright Saudi Binladin Group

5.1 No of Internal Audits ‫تقارير المراجعة الداخلية‬

5.3 Safety Consultant Tours ‫جوالت السالمة من قبل استشاري السالمة‬

5.4 Safety Consultant Observation (Close / Open) ‫مالحظات استشاري السالمة‬

5.5 K P I Rates ‫مقياس معدل االداء‬

6. SPI Results ‫نتائج تقييم مستوى السالمة‬

TOPICS DISCUSSED at Tool Box Meeting ‫الموضوعات المطروحة للنقاش‬

ATTENDANCE ‫كشف الحضور‬

7. ATTACHMENTS -None- ‫المرفقات‬

Instructor(s): ‫المشرف العام‬

PREPARED BY: ‫إعداد‬ REVIEWED BY: ‫مراجعة‬

SIGNED BY ‫الذي وقعها‬ Date ‫التاريخ‬

Copyright Saudi Binladin Group

DAILY SAFETY INSPECTION CHECKLIST

Name(s) of person(s) participating in this

PERSONAL PROTECTIVE EQUIPMENT ( ‫) معدات الوقاية الشخصية‬ REMARKS

Hand protection used/worn as required? ‫واقي اليد متوفر ومستخدم؟‬

Foot protection worn as required? ‫واقي األرجل متوفر؟‬

Hard hats worn on work site? ‫الخوذة متوفرة‬

MATERIAL HANDLING ( ‫) مناولة المواد‬ REMARKS

Sloping, shoring evaluated and is safe? ‫عمل االنحدارات والتدعيم‬

HAND TOOLS/POWER TOOLS ( ‫) االدوات اليدوية‬ REMARKS

GENERAL SAFETY ( ‫) السالمة العامة‬ REMARKS

Copyright Saudi Binladin Group

Tool-box talks conducted and documented?‫عمل محاضرات التوعية اليومية‬

)‫(إعداد‬Prepared by: )‫ (مراجعة‬Reviewed by:

Copyright Saudi Binladin Group

Case Date of Name of Nature of Injury, Body