Classification: Internal

Business Partner Work Safe Daily Declaration -13(2) Appointee

In accordance with Regulations 13 and 18(3) of the Mines, Quarries, Works and Machinery Act, I,
_____________________________________________ duly and legally appointed as a Supervisor under
Regulation 13(2) of the Mines, Quarries, Works and Machinery Act, hereby declare that;

1. I have to the best of my knowledge and ability examined my work area, assessed the task and
identified all the potential energies and inherent risks thereto.
2. I have identified all the controls necessary and appropriate for the prevention of potential
incidents
3. I have ascertained that the work to be executed has a detailed Work Execution Plan (method
statement), JRA and SWP and that all my team members are knowledgeable of the inherent risks
associated with the task.
4. I have made available all the required tooling and equipment for work execution and all the tools
and equipment have been duly inspected by a competent person and records maintained.
5. I have de-energized all potential energy sources prior to starting the task.
6. All my team members have isolated and locked out the unit we are working on.
7. Any act of omission, violation, non-adherence to the method statements, SWP, JRA and critical
controls shall result in disciplinary action and possible revocation of my legal appointment.

Signed
1. Supervisor (Legal Appointee)

Name and Surname Appointment Company Signature Date and time

NB Supervisor to complete at the start of every shift.

2. Debswana Project Team representative

Name and Position Company Signature Date and time

Surname

NB: Project Supervision representative to sign within 2 hours of shift start.

Doc No.: FRM-PMO-ECOHS-15 Name: Business Partners Daily Declaration(13.2) Issue No.: 01 Page 1 of 1
This document is maintained in the EDMS, check the validity on the EDMS before using the hard copy