Key Risk Compliance Check sheet

*UNIQUE SAFETY PASSPORT NUMBER :

Riding a two wheeler, Driving a 4 wheeler, Working on electrical systems and Working at height are key high risk activities at VIL. This

*Passport size

check sheet has been designed in such a way that necessary compliance and communication is obtained from the individual before or as

Photo

soon as possible during onboarding in VIL business. The appropriate columns / section need to be filled and cross checked as per the
applicability / nature of job. Scope - All who are required to be working on behalf of VIL. This sheet should be available at all locations
where onboarding / joining takes place across all functions and all levels. The filled sheet needs to be reviewed by the respective
manager / contract co-ordinator / contractor and records maintained. The filled sheet should be submitted to VIL on demand .

SECTION FOR INDIVIDUAL PARTCULARS

*Name :-_______________________________*Surname:-______________________*Fathers Name:-___________________________
* Mobile No:-___________________________ *Date of Joining:-__________________Blood Group:-_____________________________
*Employee No. :-________________________ *Gender: - Male Female

*Date of Birth : - ___DD__ / __MM___/ _YYYY___

*Agency / Employer: - ___________________________________________________ *Role: - __________________________________

*Function: - ____________________________ * Circle:-_______________________ * Zone:-__________________________________
*In Case of Emergency (ICE) Contact name:-___________________________________* Contact No:- _____________________________
*Do you

Drive 4 Wheeler

Ride 2Wheeler

Work on Electrical system

Work at Height

Others

Note: Fill appropriate sections below as applicable.

SECTION FOR RIDERS (2 WHEELER)

DRIVING LICENSE
**DL No: - ____________________________ **Valid till:- _ DD _ / _ MM __/ ___ YYYY __

**DL Copy Submitted:- Yes / No

HELMET
**ISI marked:-

Yes / No

Helmet Visor:-

**Full Face Helmet :- Yes / No;

Ok / Not Ok ;

VEHICLE

Helmet Chin Strap usable:- Yes / No;

Registration No. :- ___________________

Vehicle Age (Yrs.) :- ______________

**Valid Insurance: -

Visual tyre condition:- OK / Not OK;

Head Light :-

Additional Information
Reflective Jacket:-

Helmet Conditions :- Ok / Not OK ;

Make: -___________________________

Yes / No

Rear View Mirrors:-

OK / Not OK;

Ok / Not Ok;

Tail Light:-

OK / Not OK ;

Role involves riding 2 wheeler after sunset : Yes / No

Reflective Tape on Helmet:- Yes / No

Yes / No ;

Reflective Tape on Bike:- Yes / No;

SECTION FOR DRIVERS (4 WHEELER)

DRIVING LICENSE
**DL No: - ____________________________ **Valid till:-_ DD__ / __MM___/ _YYYY___

**DL Copy Submitted:- Yes / No

VEHICLE

Make: -________________________

Registration No. :- ___________________

Vehicle Age (Yrs.):- ______________

**Valid Insurance: -

**Rear Seat Belts:- Yes / No

Head Light:-

Yes / No

Rear View Mirrors:- OK / Not OK,

Ok / Not Ok;

Tail Light:-

** Front Seat Belts :-

Yes / No

Visual tyre condition:- OK / Not OK;

OK / Not OK ;

SECTION FOR 2 WHEELER RIDERS & 4 WHEELER DRIVERS

I am aware that:Unauthorized person should not accompany while riding / driving for Vodafone business

Yes / No

Night driving / riding for Vodafone business during restricted hours (between 10 pm to 5 am) is prohibited

Yes / No

Max. 2 people are allowed on 2 wheelers

Yes / No

** I agree to abide by above VIL driving requirements and will comply them as and when applicable.

Yes / No

Any other Comments - ___________________________________________________________________________________________

**Signature: - ___________________________________________________________________________ ____

Prepared and circulated by Corp HSW

**Date : - DD_ / MM_/ _YYYY

Version 3, Dt. 5sh April 2014

Key Risk Compliance Check sheet

SECTION FOR WORK AT HEIGHT
**Availability of VIL apporved Full Body Harness :- Yes / No ;

**Experience to Work on Height (Yrs.) :- ___________;

**Fit to Work at Height Medical Certificate Available & Copy submitted:- Yes / No;
** Training:-

Advance Training on Height & Recue (ATHR)

Contractors Basic Training on Height & Rescue (CBTHR)

Formal Training - Others (Pl Specify:-_____________________________________**Training Certificate submitted:I am aware about:

Work permit for work at height is supposed to be issued before start of work
Use of Personal Protective Equipment (Full body harness) required for height work
The restrictions/ special permission to work at Height during night /other environmental conditions
Work restrictions / refusal if not feeling well / medically un-fit
**Signature : - ______________________________________________

Yes / No

Yes / No
Yes / No
Yes / No
Yes / No
**Date : - DD_ / MM_/ _YYYY

SECTION FOR WORK ON ELECTRICAL SYSTEMS

**Qualification:- 10th Grade

12th Grade

Diploma Electrical / Electronics

BE (Equivalent) Electrical / Electronics

Electrical License

ITI Electrical

ITI Others (Pl Specify):- _______________________

**EL No: - _________________________ **Valid till:- DD_ / MM_/ _YYYY _**EL Copy Submitted:- Yes / No;

**Issued By :- __________________________________________________________________________________________________
**Fit to Work on electrical system - Medical Certificate available & copy submitted:-

Yes / No

Experience to Work on Electrical Systems (Yrs.):- _____________Electrical Training, if any (pl. specify) :-_____________________________
I am aware about work permit for electrical isolation

Yes / No

I am aware about restriction to work on Live or High Tension Electrical System

Yes / No

**Signature : - _____________________________________________________

**Date : - DD_ / MM_/ _YYYY

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6.

Section Applicable to All - Questions / Checks

*Have you undergone the HSW Induction?
*Do you understand the Vodafone India 7 Absolute Safety Rules?
*Have you understood the individual responsibility for HSW?
*Do you understand the 3 Key Risks for VIL are related to Driving @Work, Electrical Safety & Working @Heights?
*You are aware about Refusal to Work and your rights to refuse if work is unsafe?
*Were you explained the Consequence Management Matrix and understand the implication of violation?

Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No

*You understand that in case of any High- High severity violation your employment / engagement with
VIL can be terminated immediately?
Yes / No
8.
*Are you aware that all incidents / accidents are to be reported?
Yes / No
SELF DECLARATION: - I assure that above mentioned particulars are true & correct to the best of my knowledge and belief. In future I will
abide by all the Vodafone HSW rules as explained to me.
*Date: - DD_ / MM_/ _YYYY
Location: - ____________________________ *Signature: - ________________________________
REVIEWER SECTION - Section Applicable to All
7.

AGENCY/CONTRACTOR/ SERVICE PROVIDER/DISTRIBUTOR:-

*Distributor /Contractor/ Principal Company :- _____________________________ Sub Agency / Contractor:-________________________

Reviewers comment (if any) : - ____________________________________________________________________________________
*Name:- _______________________________*Signature: ____________________ Stamp :-___________________________________
VODAFONE LINE MANAGER:-

*Allowed to:- Drive 4W

*Licenses & Certificates checked & attached Yes / No

Ride 2W

* Safety Passport Issued:- Yes / No

Work on Electrical system

*HSW Induction given:-

Work @ Height

Yes / No

Others

Reviewers comment (if any) : - _______________________________________________

*Name: - _____________________________* Emp. No:-___________________________*Mobile No:-____________________________

*Email id :-____________________________________________________*Signature:-___________________*Date:- DD_ / MM_/ _YYYY
(Note to Reviewer : Ensure if the qualification and experience is in line with VIL Electrical Standard for the person exposed to electrical risk.)

Prepared and circulated by Corp HSW

Version 3, Dt. 5sh April 2014