Contractor HSE Monthly Report

Contractor Company Name *

Month *

Year *

Number of hours worked at ADG this month *

Number of lost time injuries? *

Number of medical treatment injuries? *

Number of first aid injuries? *

Number of hazards identified? *

Number of near misses identified? *

Number of property damage events? *

Number of safe work method statements (SWMS) or Take 5’s used over the month? *

Number of meetings conducted where HSE discussed? *

Was there any HSE events that occurred in ADG-controlled areas? *

YesNo

Please provide information on any HSE events that occurred in ADG-controlled areas. Minimum information should include:

The date, time and location of the incident.
The name/s of those involved (including witnesses).
The outcome of the incident (i.e. MTI, no injury, property damage, etc).
The identified immediate and root causes of the incident and corrective actions.
The name and contact details of the person conducting the investigation.

Date *

Details *

Actions completed? *

Please attach the reports for all actions completed for all the HSE events *

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Name *

Position *

Email address *

Signature *

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Date *

CAPTCHA *

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