SPACE INTERRIOZ

Screening Of Worker
Worker ID No:- Date:-

Name of the Contractor :

Full Name of the workmen: PHOTO

Mobile Number:

Father Name:

Address:

Date of birth Age Sex

Marital status:- Married / Single

Mother Tongue Other Languages Known

In case of emergency person to be contacted Contact Number

Declaration by the Worker

The above information given by me is correct to be best of my knowledge

Signature / Left Hand Thumb impression of the Worker :-

Declaration by the Subcontractor / Contractor

We declare that this employee will be working for us in this side He / She shall follow the entire site safety requirement We take responsibility for his/her safety in
the site

Signature of the Contractor:-

Name & Signuture

Comments by the Company Representative

Screened by me & Certificates / Details verified / Not verified

Name & Signuture

Suitable for employment as

Non Compliance Record

1. First HSE violation discription :-

Date
HSE Officer (Remarks/Name &Signature)

2. Second HSE violation discription :-

Date
HSE Officer (Remarks/Name &Signature)

3. Third HSE violation discription :-

Date
Due to no positive behavioural change, this ID card has been revoked & the worker has
HSE Officer (Remarks/Name &Signature) been asked to reattend the induction briefing.