Field Assesment Form Site Safety Supervisor

Name Of Candidate-: BATCH NO-: RFID No./SAFETY PASS NO:-

Programs Shadow STINT/On The Job Training Vendor-: Vendor Code-: Date-:
Shadow STINT Month#1 Month#2 Month#3 ___________________ / /
Target/
Sl. No. Criteria of Evaluation Total Average Total
Month Part-1 Part-2 Part-1 Part-2 Part-1 Part-2 Part-1 Part-2 Scored Remarks
(%) Marks
1 Attendance (Days Present) 26
2 Punctuality ( Nos of Delay) 26
3 Participation in Safety Audits 4
4 Participation in Line Walk 1
5 Participation in Contractor AIC Meeting 1
6 Nos of Tool Box Meeting Participated 26
7 Nos of Mass meeting Conducted 1
8 Nos of Open Safety Observations Registered 20
9 Nos of Open Safety Observations Closed 20
10 Nos of Near Miss Registered/ Reported 5
11 Nos of Mock Drill Conducted/ Participated 1
12 Nos Incident /Near-missReported (If Any) 1
13 Nos of One Page Report Prepared (If Any) 1
Nos Of Safety Training Conducted (SOP/Fire
14 Safety/Emergency Preparedness/Work Place 4
Safety/Any 0ther)
15 Any Improvement Project 1
Total
*Contractor's *Opportunity For Improvement (OFI)
Feedback………………………………………………………………..……………………………………………………………………………...…………………………………………………….

*We want to retain him. (Please tick any one) Yes No

Signature (Candidate) Signature (Contractor)

Part-1 13 Days
Part-2 13 Days
Total 26 Days 1 Month
Star marks or Heavy line board must be fill yourself