MONTHLY INJURY & HEADCOUNT REPORT

To: CEO

Herewith is the summary of “Contractor’s Monthly On-Job Injury and Headcount Report for the month of”
November, as per G.I. 6.007.

Contractors’ Employees Total Recordable Injury/Illnesses Cases

Report Duration
Total Head Count (TRC’s)
1445 NIL NIL

SUMMARY
Headcount
Contractor Name & Number Location Head No. of Remarks
Count Injuries
Dhahran 71 Nil Nil
Dhahran 404 Nil Nil
Dhahran 351 Nil Nil
Dhahran 558 Nil Nil
Dhahran 33 Nil Nil
Dhahran 24 Nil Nil
Dhahran 4 Nil Nil

On-job injuries /Occupational Illnesses (if any)

Employee Information Description / Type of Injury (pls. check)
Name Badge no. Nature of Injury FAT LTI RDI MTC FAI
1. Nil
2. Nil
Note: Any accident, attach filled up SA Contractor Injury Report Form
Legend (per G.I. - 007) : FAT- On-Job-Fatality; LTI- Loss Time Injury/Illness case: RDI- Restricted Duty Injury/Illness
case; MTC- Medical Injury/Illness case, FAI- First Aid Injury case; TRCs- Total Injury/Illness Case

Remarks:

Submitted by (Name & Signature) _________________ Noted by. ______________

Safety Coordinator, HSE Manager

Cc: File
Contract Advisor