MONTHLY HSE STATISTICS REPORT

Date:
Project Title: Contract / CRC No.:

Name of the HSE Staff: Month: Report No.:

Lost Time Accident

Number of Accidents
Employee Date and Time
Name of Injured Location Days Lost Current
Number of Accident Cumulative
Month

Motor Vehicle Accidents/Non Collision Damages

Number of Accidents
Employee Date and Time Vehicle
Drivers Name Location Current
Number of Accident Number Cumulative
Month

Heavy Equipment Accidents

Operator’s Employee Type of Date of Suwaidi Number of Accidents
Location
Name Number Equipment Accident Number Current Cumulative

Fire or Explosion Incidents

Employee Date of Time Time Property Number of Incidents
Name (If Any)
Number Fire Started Extinguished Damaged Current Cumulative

Incidence (Dangerous Occurrences)

Employee Date of Property Number of Incidents
Name (If Any) Trade Time Location
Number Incident Involved Current Cumulative

Man-hours of Current Month: Cumulative:

___________________________ Noted by: ________________________________________

HSE Staff Signature Project Manager/Supt./In-Charge

DISTRIBUTION: Project Manager HSE Manager Project HSE Staff

NOTE: 1. To be filled on the last day of every month.

Revision No. 04 Page No. 1 of 1 Doc. No. IS-HSE-R26

Prepared by: Management Representative Issued Date: 21st January 2018
Reviewed by: General Manager Approved by: Chief Executive Officer