Employee Safety Performance

Evaluation Form
DLPS-HSE-037/00

Employee Name: ____________________________________ Employee No.: _________________

Designation: ________________________________________ Direct Supervisor: _________________
Project: ____________________________________________

GENERAL 5 4 3 2 1 NA

Keeping the provided PPE clean and worn at site.

Attending Safety Meeting and Toolbox.

Properly uses tools and equipment

Initiating Housekeeping at work. Maintaining work area organize and
clean.
Participating in Safety Activities such as drills and others.

Participating Safety Observation Reporting

Participating in Near miss Reporting

FOR SUPERVISOR 5 4 3 2 1 NA

Treats Subordinates with respect, dignity and tactfulness while carrying

out all responsibilities
Works cooperatively with subordinate

Conveys orders in a manner that is clear and concise

Follow Permit Working Procedures

EVALUATOR
Name & Signature Name & Signature

Designation: Designation:

Date: Date:

Comments: Comments: