ARCHIRODON GROUP NV

Intergrated Management System

FORM
Monthly Health and Safety Statistics Report

Jan Feb Mar Apr May Jun Jul

Total Manhours Worked
No of Employees (Last day)
INCIDENTS
Fatalities (FAT)
Lost Time Injuries (LTI)
Restricted Work Cases (RWC)
Medical Treatment Cases (MTC)
Occupational Ill-health Cases (OIH)
Total Recordable Incidents (TRI) 0 0 0 0 0 0 0
First Aid Cases (FAC)
Near Misses (NM)
Asset Damages (AD)
Road Traffic Accidents (RTA)
TRAINING & AWARENESS
Tool Box Talks in Health & Safety Topics
Method Statement (MS) Briefings
Task Safety Analysis (TSA) Briefings
Safety Representatives Meetings
Meetings due to an accident (FAT or LTI)
Internal Training in IMS Procedures
External Training Courses
MONITOR & AUDIT
Internal Audits
Site HSE Inspections
Project/CFY Management HSE Tours
Operational Meetings (HSE aspects)
Regional HSE Manager's site visits
PERFORMANCE
Total Recordable Incident Rate (TRIR) 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Lost Time Injury Frequency Rate (LTIF) 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Days Lost due to LTI
HSE Observations Raised
HSE Observations Closed
HSE Observations Closed from Previous Months
HSE Observations Close out Ratio 100% 100% 100% 100% 100% 100% 100%

Completed By Approved By
Job Position Job Position HSE Manager
Name Surname Name Surname
Signature Signature
Date Date
 Health, Safety & Environment (HSE)
Rev.
Issue For Internal Use Only
Referance No. HSE-PRO-05-F06 0.1
Serial No.
Page
1of 1
Aug Sep Oct Nov Dec TOTAL
0
#DIV/0!

0
0
0
0
0
0 0 0 0 0 0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0

0.00 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.00 0.00
0
0
0
0
100% 100% 100% 100% 100% 100%

Distrabution List
Job Position Name Surmane
HSE Manager
Regional HSE Manager
 ARCHIRODON GROUP NV
Intergrated Management System

FORM
Monthly Health and Safety Statistics Report

Jan Feb Mar Apr May Jun Jul

Total Manhours Worked
No of Employees (Last day)
INCIDENTS
Fatalities (FAT)
Lost Time Injuries (LTI)
Restricted Work Cases (RWC)
Medical Treatment Cases (MTC)
Occupational Ill-health Cases (OIH)
Total Recordable Incidents (TRI) 0 0 0 0 0 0 0
First Aid Cases (FAC)
Near Misses (NM)
Asset Damages (AD)
Road Traffic Accidents (RTA)
TRAINING & AWARENESS
Tool Box Talks in Health & Safety Topics
Method Statement (MS) Briefings
Task Safety Analysis (TSA) Briefings
Safety Representatives Meetings
Meetings due to an accident (FAT or LTI)
Internal Training in IMS Procedures
External Training Courses
MONITOR & AUDIT
Internal Audits
Site HSE Inspections
Project/CFY Management HSE Tours
Operational Meetings (HSE aspects)
Regional HSE Manager's site visits
PERFORMANCE
Total Recordable Incident Rate (TRIR) 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Lost Time Injury Frequency Rate (LTIF) 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Days Lost due to LTI
HSE Observations Raised
HSE Observations Closed
HSE Observations Closed from Previous Months
HSE Observations Close out Ratio 100% 100% 100% 100% 100% 100% 100%

Completed By Approved By
Job Position Job Position HSE Manager
Name Surname Name Surname
Signature Signature
Date Date
 Health, Safety & Environment (HSE)
Rev.
Issue For Internal Use Only
Referance No. HSE-PRO-05-F06 0.1
Serial No.
Page
1of 1
Aug Sep Oct Nov Dec TOTAL
0
#DIV/0!

0
0
0
0
0
0 0 0 0 0 0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0

0.00 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.00 0.00
0
0
0
0
100% 100% 100% 100% 100% 100%

Distrabution List
Job Position Name Surmane
HSE Manager
Regional HSE Manager