Form E4

General Information
Classification
Name of Entity:
Code:

Type of Business Activities:

 Building and Construction  Education  Energy

 Food  Commercial  Health

Sector Name:
 Industry  Tourism  Transport

 Waste

Telephone No.: E-mail Address:

Address:
Fax No.: P.O. Box:

Authorized Contact Person:

Authorized Contact Person Position /

Title:
Telephone No.: E-mail Address:
Contact Details of Authorized Person:
Fax No. : P.O. Box :

Annual Budget allocated for OSHMS

Year:
implementation (AED):

Details of Actual Expenditure (during the same year)

1. OSH Management Costs (AED)

OSH Manpower Direct Costs OSH Manpower Indirect Costs
(Salaries of full time OSH staff, Part time (Man hours lost for non-OSH staff who have
OSH staff, internal OSH consultant and spent time managing OSH issues, through
Manpower: related financial costs) supervision, inspection, internal audit, etc)

OSH Training Indirect Costs

OSH Training Direct Costs
(Man hours lost during internal and external
(Internal and external OSH training)
Training: training)

OSH Awareness Events/Campaigns OSH Awareness Events/Campaigns Indirect

Direct Costs Costs
(Costs of OSH special events/campaigns) (Man hours lost during OSH special
Events/Campaigns: events/campaigns)

OSH Consultancy Costs

(Cost of consultancy services for gap Third Party Audit
analysis, risk assessment, system (Cost of third party annual audits)
Consultancy/Audits: development, etc)

OSH Equipment Capital Costs

(Purchase of OSH equipment, such as fire
extinguishers, first aid kits, etc. and cost of OSH Equipment Maintenance Costs
(Maintenance of OSH equipment)
Equipment: safety system purchases or upgrades such
as alarm systems)

Other Costs related to/associated with OSH Management:

OSHAD-SF – Forms
Form E4 – OSH Implementation costs in Entities within Sectors – Version 3.0 – 1st November 2016 Page 1 of 2
Form E4

2. OSH Incidents Costs (AED)

Repair & Maintenance Costs Replacement Costs
(Property, Machinery, Structure, Vehicle, (Property, Machinery, Structure, Material,
Assets: etc.) Vehicle, etc)

OSH Incident Scene / Area Restoration

Productivity Loss
Costs
(Includes total value of production, total man
(Cost of cleanups, arrangement to make the
Restoration/Productivity: hours, total work hours lost )
area safe)

Legal Cost Compensation

Penalties
(lawyers, Judicial prosecutions, etc) Claims
Legal:

Injury Cost
Other Costs
(Treatment, Hospital, Transport, Insurance,
(relevant to / associated with the Incident)
Injury: etc.)

OSH Management OSH Incidents Costs Grand Total

Total Expenditure for OSH Costs (AED) (AED) (AED)
Implementation:

Comments (Please add any additional comment if needed)

Declaration

I declare that all information provided in this document is true, correct and complete.

Signature of the
Official
Authorized Contact
Stamp :
Person:

Date :
_____/_____/_____
(DD/MM/YYYY)

OSHAD-SF – Forms
Form E4 – OSH Implementation costs in Entities within Sectors – Version 3.0 – 1st November 2016 Page 2 of 2