Client: Health and Safety Monthly Performance Summary Report

……………………………………………..
Project Name.:
…………………………………….
Project No.:
………………………………………..
Location: Month: Year: Engineering & Construction Co. L.L.C
…………………………………………..
REACTIVE Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec YTD
ALSA
No. of Employees Sub-Contractor
Total
ALSA
Total Man Hours Sub-Contractor
worked
Total
ALSA
Fatalities
Sub-Contractor
ALSA
> 3 days
Lost Time Injury Sub-Contractor
LTI ALSA
< 3 days
Sub-Contractor
Number of Days ALSA
Lost Sub-Contractor
ALSA
First Aid Incident
Sub-Contractor
No. of Cases
Restricted Work
No. of Days
Medical Treatment ALSA
Case (MTC) Sub-Contractor
Incident Frequency ALSA
Rate (LTIF) Sub-Contractor
ALSA
Severity Rate
Sub-Contractor
Total Number
Vehicles Kilometers Driven
No. of Accidents
ALSA
Property Damage
Sub-Contractor
Near Misses Total Number
Security-related Issues Total No.

Man Hours Worked since ALSA

Last LTI Sub-Contractor
Total Man Hours Worked since Last LTI
Days since Last LTI
Client:
…………………………….
PROJECT HEALTH AND SAFETY PERFORMANCE SUMMARY REPORT
Project Name:
……………………
Project No.:
………………………..
Location: Month: Year:
………………………….. Engineering & Construction Co. L.L.C
PROACTIVE Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec YTD
ALSA 0
No. Of Employees Sub-Contractor 0
Total 0
ALSA 0
Total Man-hours worked Sub-Contractor 0
Total 0
GENERAL
ALSA 0
Management
Sub-Contractor 0
ALSA 0
Meetings Supervisory
Sub-Contractor 0
ALSA 0
Tool Box Talks
Sub-Contractor 0
ALSA 0
Overall
Sub-Contractor 0
ALSA 0
Jobsite
Sub-Contractor 0
Inspections
ALSA 0
Tasks
Sub-Contractor 0
ALSA 0
PPE
Sub-Contractor 0
ALSA 0
Number
Sub-Contractor 0
Training
ALSA 0
Hours
Sub-Contractor 0
Emergency Drills Total Number
SPECIFIC
Procedural ALSA 0
Reviews Sub-Contractor 0
Hazard ALSA 0
Identification &
Risk Assessments Sub-Contractor 0
HSE Plans ALSA 0
Reviewed Sub-Contractor 0
On Site ALSA 0
Sub-Contractor 0
General Promotion
Off Site ALSA 0
Sub-Contractor 0
Prepared By:
Name: Title: Date: Signature