HSE Formats
HSE Formats
HSE Formats
0 HSE Forms
2.1 HNE-HSE-F-01 Contractors Safety Information
2.2 HNE-HSE-F-02 Tool Box Talk
2.3 HNE-HSE-F-03 HSE Meeting Report
2.4 HNE-HSE-F-04 Safety Observation Report
2.5 HNE-HSE-F-05 Environment Incident Report
2.6 HNE-HSE-F-06 Corrective Action Request
2.7 HNE-HSE-F-07 Course Attendance Sheet
2.8 HNE-HSE-F-08 Training Calendar
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This information applies to HNE and others sub contractors under their control engaged in
carrying out work on the project and premises.
It is HNE’s intention to secure a high standard of health safety and environment compliance in
all our areas of control.
HNE will comply with national and local health and safety legislation and codes of
practices and Client / Consultant HSE rules / HSE Plan whilst on site.
HNE submit risk assessments and method statements for all activities and get the Client /
Consultant approval before carrying out the work. HNE will adhere to the identified
control measures while executing the work activity.
When changes in health and safety controls may be necessary, such changes will be
informed to the Client / Consultant HSE personnel. This will cover for example hazards,
restricted access areas, fire precautions, emergency response, first aid facilities, accident
reporting, welfare facilities, smoking restrictions, segregation of work activities, any
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(* If this pertains to the sub contractor employees, indicate the name of the
contractor) Toolbox talk was given by:
Name :
Position :
Signature :
Place:
Date: Time:
Minutes recorded by: Signature:
Action by Closed
Sl.
Description / Target out (Date
No
Date & Sign)
1. Purpose and objective of the meeting:
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Housekeeping:
Edge Protection:
4. Welfare measures:
Rest Area:
Toilets:
Drinking Water:
5. Safety Incentive Scheme:
9. PTW issues:
1. Hot Work:
2. Barricade Removal Permit System:
3. Excavation
4. Confined Space
5. LOTO
24. PPE:
25. Security:
26. Any other issues:
27. Next meeting:
Contractor :
Date :
SL
OBSERVATIONS ACTION TAKEN
NO
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Inspected By :
Report To :
This report shall be returned within 24 hours to the Contractor’s Safety Personnel
indicating action taken against the observations made.
Date of Incident :
Air Emission
Water Pollution (Wastewater Discharges / Sanitary Waste)
Solid or Hazardous Waste
Hazardous Materials or Chemicals Used / Stored
Noise Pollution
Odour / Dust
Water / Fuel / Electricity Consumption
Other
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Details of Incident
Reported By Date
Root Cause
Investigated By Date
Action Taken
Taken By Date
Review & Close out
CAR Ref :
Raised By Date
Results of Investigation & Root Causes
Investigated By Date
Corrective Action
Date
Trainer
Trainer Signature :
Year
Course Title Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
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Signature:
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Pr Gauge
Location
Safety Clip
Remark/Sign
ConditionHose
InspectionDate Of
Inspection 3rd Party
Sl Type Of Fire
no Extinguisher
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Inspected by :
Signature :
Date :
You were found working unsafely / allowing the operatives working under you to carry out
work in on unsafe manner thus putting in danger their lives as well as others working nearby.
The violation is as follow:
Is the violator given sufficient training related to the type of violation [Yes / No]
Safety training (Induction, specific training) reference to be attached with reference to the type
of safety violation.
This is against our company safety policy and the local rules governing the Health and Safety of
employees. The following action will be taken against you:
Repetition Nos. Action Taken
st The employee will be called during the toolbox talk and will be asked to address others the
1 Warning
circumstances in which he was forced to take the shortcut (follow the unsafe practice) and
/
how it can be avoided; he has to also apologize for the said act and promise the whole
Repetition
group that he will not repeat the same in future
nd
2 Warning Concerned employee along with his supervisor will be asked to report to the Company HSE
/ Manager. Contractor HSE Officer shall coordinate this. After appropriate counselling, both
Repetition of them will be issued with a warning letter.
The Contractor employee, along with his supervisor shall be summoned to the Company
Office; issued with a termination/ de-mobilized notice by the Company HSE Manager and
shall not be allowed to work within the Company premises.
rd
3 Warning Any Contractor staff found working within the Company premises without a valid (UAE)
/ work permit; he/she along with his supervisor shall be issued with a termination/ de-
Repetition mobilized notice immediately by the Company HSE Manager and will be asked to leave
Company premises. Contractor will be given 24hours to submit the original work/permit to
Company HSE, failing which contractor will be asked to permanently demobilize the
identified staff and his immediate supervisor from the site.
Safety violation noticed by: Safety Warning issued by: Warning Accepted by:
Name:
Designation:
Signature:
Description of the work: Arc welding / C utting / Grinding near flammables / Soldering / Brazing
/Metal cutting / Electric Cable termination and jointing
Section II:(Request for the permit) Permit Receiver to mark all boxes either with (only for
relevant ones) or mark as X
No flammable/combustible materials around/below Suitable Fire Extinguisher and trained personnel
the work spot. (Operation of Fire extinguisher) at the work place
Wet gunny bag/fire resistant sheet to arrest flying spark Welding m/c with proper insulated welding
cable/lugs
Standby person for watching falling molten metals. Welding & supply cable without joints/ damages.
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Gas cutting torch fitted with Flash back arrestor. Separate Ele. supply cable with ELCB from DB
Soap water test conducted for detecting leakage. No criss-cross of power & welding cables
Gas Cylinder with proper Pressure Gage & Regulator. Proper/overhead routing of Electrical cables
Gas Cylinders with Chain/ trolley to arrest falling. Availability of proper scaffolding/platform/ladder
Gas Hose of sound condition & proper hose clips. Proper ventilation
Suitable Spark lighter available- never use smoking lighter. Separate permit incase of work in confined space
Barriers to avoid exposure of UV / IR rays to passers Safety inducted welder / Helper and others involved
Do not gas cut containers of flammable liquids. Required PPE for helper
PPE - Helmet Welding Screen Suitable Goggles Welding Apron
Dust Masks Leather Hand Gloves Safety Shoes Full Body Harness
Any other precautions (Specify):
I request for a Hot Work Permit for the above-mentioned work at the location specified
above. I have personally inspected the work place to ensure that the applicable precautions
mentioned above have been complied with.
Name: Signature:
Section III: (Permit Approval - To be filled by authorized Issuer)
I have personally verified the work spot and compliance of the relevant precautions given in
section II of this permit.
Section II:(Request for the permit) Permit Receiver to mark all boxes either with (only for relevant
ones) or mark as X
Suitable & Sufficient access provided to the confined
All the employees trained in working in confined space?
space?
Required warnings signs (Danger – Restricted Entry, Gas test been done to check the absence of flammable
Permit Required), Emergency Contacts no displayed gases
If any other gases are anticipated, has it been checked? Have low voltage & flameproof lighting been arranged?
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Confined space checked for oxygen deficiency All concerned persons been informed
Enough ventilation ensured. Entrants provided with emergency lights
A stand-by (Buddy) is deputed outside the manhole / In-Out Register ready to maintain / Available with
confined space buddy
All entrants provided with safety harness with long
Necessary safety appliances been provided
lifeline
Any other precautions (Specify):
LEL
Oxygen
I request for a Confined Space Entry Permit for the above-mentioned work at the location
specified above. I have personally inspected the work place to ensure that the applicable
precautions mentioned above have been complied with.
Note:
1. Total 2 copies-Original at the work place, Second copy-with issuer; Closed permits (Original)
to be submitted to Safety
2. The permit must be registered and a unique number to be given for each permit for follow up.
3. Percentage of O2 should not be less than 20%
4. This permit is valid only for the location mentioned in section I and for one day only.
5. Permit can be cancelled at any time if any violation observed.
Section II:(Request for the permit) Permit Receiver to mark all boxes either with (only
for relevant ones) or mark as X
Sufficient training conducted for concerned staff and
Competent working crew has been deputed
documented
Power supply switched off Circuit breaker Deactivated
Isolator switch locked* Required warning notices” DANGER”, “RESTRICTED
ENTRY”, “HIGH VOLTAGE TESTING IN
Earthing available
PROGRESS”,
All testing equipments are calibrated and
All floor & roof openings are covered and barricaded
sticker available
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I request for a Pre Commissioning Testing Permit for the above-mentioned work at the
location specified above. I have personally inspected the work place to ensure that the
applicable precautions mentioned above have been complied with.
Name: Signature:
Section II:(Request for the permit) Permit Receiver to mark all boxes either with (only
for relevant ones) or mark as X
Required permit for buried services has been Workers are given training – Risk Identification
obtained from the concerned authority. and Precaution
Are all the buried services located (with the Required caution boards / warning notices are
help of drawings and by trial pit, detectors etc) provided
Is Shoring / sloping required? If so, has the Barricades / Handrails installed around the
material been arranged? proposed excavation site
The access details to the pit finalized and Are any traffic diversion signs / flashers required If
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I request for an Excavation Permit for the above-mentioned work at the location specified
above. I have personally inspected the work place to ensure that the applicable precautions
mentioned above have been complied with.
Name: Signature:
Note: This form is to be filled immediately in case of injury / illness immediately and submitted
to Company HSE Personnel.
Incident Description
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Primary Cause
Contributory Factors
Protective Equipment not used Yes No Inattention Yes No
Protective Equipment not Yes No Fatigue Yes No
available
Identified controls and given Yes No Defective Equipment Yes No
instructions not followed
Lack of Communication Yes No Poor Judgment Yes No
Lack of Training Yes No Poor Housekeeping Yes No
Contributory Negligence by Yes No Shortcuts Yes No
Others
Project Manager /
Construction
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Manager
Add pictures of Incidents
Picture 1 Picture 2
Distribution:
Contractor Date
Employee Name Location.
Section 1: Problem Description (Please write what you observed, you may write in any language)
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Note: * If the violator belongs to a sub contractor, indicate the name of the company.
* If the injured belongs to a sub contractor, indicate the name of the company.
** Mention what the injured was doing, the equipment, material he was handling at the time of accident etc.
PROJECT NAME:
Sl No Description Observation Remarks Action By
EXCAVATION
SCAFFOLDS
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CONCRETING
WORK AT HEIGHT
MATERIAL HANDLING
GRINDING
FIRE PROTECTION
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HOUSEKEEPING
ENVIRONMENT
Updated On:
Updated By:
10
Document Issued to
Sl Name of the Document
Name / Title Date Signature
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