MONTHLY HSSE STATISTIC AND PERFORMANCE

Name of Project /
Division / Area

This M
No.

Data Required

GENERAL
1.1
Man hours worked
1.2
Man hours since last LTI
2
Senior Management Site Visits (Mgr's and above)
3
Site HSE Committee Meetings
4.1
4.2
4.3

A
U
D
I
T

Internal HSE-MS Audits

Internal HSE-MS Audit Action Items Closure
Contractor HSE-MS Audits

Units

NO.
NO.
NO.
NO.
NO.
%
NO.

6.1

Contractors HSE-MS Evaluation during bidding

NO.

6.2

Contractors Performance Evaluation for completed projects

NO.

SAFETY
7
Noise Mapping
8
CHRA
9
PTW Assessment/Review
10
Medical Evacuation (MEDEVAC)
HSE DRILLS
11
Please Indicate :
U-SEE-U-ACT
12
Unsafe Act
13
Unsafe Condition
INCIDENTS
14
Fatalities
15.1
Permanent Total Disabilities
L
15.2
Permanent Partial Disabilities
T
15.3
Lost Workday Case
I
15.4
Workdays Lost
16
Restricted Work Cases
17
Medical Treatment Cases
18
First Aid Cases
19.1 P
Property Damage/Loss
D
19.2
Property Damage/Loss Costing (estimated cost)
20
Fire or Explosions
21
Near Misses
22
Man Overboard
23.1 O
Occupational Illnesses
H
23.2
Total Sickness Absentism
24
High Potential (HiPo) Incidents (from incidents stated above)
25
Commuting/Traffic Incidents (Company owned)
26
Commuting/Traffic Incidents (Privately owned)

NO.
NO.
NO.
NO.

NO.

NO.
NO.
NO.
NO.
NO.
NO.
Days
NO.
NO.
NO.
NO.
MYR

NO.
NO.
NO.
NO.
Days
NO.
NO.
NO.

PESB

27
Security Incidents
HEALTH
28
Medical Referral Cases
29
Hygiene Inspections

NO.

30
Medical Health Declaration with health conditions
31
Audiometric Testing
ENVIRONMENT

NO.
NO.

NO.
NO.

32

Scheduled Wastes + Dangerous Drugs Wastes (please attach inventory)

Kg

33

Non-scheduled Wastes (solid wastes) (please attach inventory)

Kg

34

Non-scheduled Wastes (construction wastes) (please attach inventory)

Kg

35
36
37
38
38.1
38.2
38.3
38.4
38.5

Air Emission
Oil Spill Drills
Fuel Consumption
Bilge/Industrial Effluent Discharge
- Onshore Facilities (Oil & Grease)
- Offshore Facilities (Oil in Water)
Barge/Vessels
Mobile Offshore Drilling Unit
Offloading Facilities (e.g. FPSO)

g/Nm3
NO.
Litres
ppm
ppm
ppm
ppm
ppm

This M
No.

Data Required

C
39
Spills
H
E
39.1 M
Number of Chemical spill incidents
I
39.2 C
Volume
A
39.3 O
Number of oil spill incidents
L
I
39.4 L
Volume
40
Hydrocarbons released*
LEGISLATIVE COMPLIANCE

41
HSE Legal Compliance Status
42.1 Fines & Summonses (from authorities)
42.2
- Amount (estimated cost)
OTHERS
43
Security Audits
44
Piracy/Security Drills
45
HSE Plan & Programs (please indicate) :
46
47
48

HSE Non-compliance
Consequence Management Cases
Management Review

*Please indicate Not Applicable (NA) for non relevant column.

Submitted by
Signature

Name

Position

Units

NO.
Litres
No.
Litres
m3
%
NO.
MYR

NO.
NO.
NO.
NO.
NO.
NO.

PESB

CE

This Month
Subcontractor

Date
Reporting Date From
To
Year to Date (YTD)
TOTAL

PESB

Sub-contractor

:
:
:
TOTAL

Remarks

This Month
Subcontractor

Year to Date
TOTAL

PESB

Sub-contractor

Approved by (HSE Manager)

Signature

Name

TOTAL

Remarks