Monthly Report FOrm
Monthly Report FOrm
Monthly Report FOrm
20
* Mandatory reporting fields *Business Area : Operation / Project: *CONTRACT COMPANY:
Prime Contractor? Yes No
Version: 00
*Month of:
D&T Water Energy Services Name MONTHLY HS&E PERFORMANCE Shared Services
Year:
Other:
SUB CONTRACTOR COMPANIES: Contacts: Contractor Manager Contractor Health & Safety Contractor Environment EPCOR Owners Representative: EPCOR Contract Coordinator : *EPCOR HS&E Advisor:
Contact Number
LAGGING INDICATORS By Business Area *Near Misses (#) *First Aids (#) *Medical Treatments (#) *Lost Time (#) *Other Recordable (#) *Lost Work Days *Restricted / Modified Work Days *Reportable Environmental Incidents (#) *Hours Worked (Regular) *Hours Worked (Overtime) *Total Exposure Hours Total Recordable Injury Frequency
Monthly Total
Year to Date
LEADING INDICATORS By Business Area Toolbox Talks Safety Meetings Orientations Inspections / Observations Corrective Actions completed Other: Other:
Monthly Total
Year to Date
FORMTEXT
REGULATORY ACTIONS OR INSPECTIONS *Did your company experience any regulatory actions or inspections this month? Report Completion Instructions Contract companies providing services to EPCOR are required to complete this form on a monthly basis. This reporting requirement applies to companies that provide maintenance, services (i.e.: janitorial, landscaping, snow removal, security, etc.) or construction in excess of 100 hours per month (including sub-contractor hours). Reporting is not required for consultants, visitors, delivery drivers, off site manufacturing, design, or servicing office equipment such as photo copiers/phones. Yes No If yes, provide regulatory agency and description of action taken
Current versions of controlled documents are posted on the EPCOR intranet. Versions obtained from other locations are considered uncontrolled. It is the users responsibility to verify that this is the current version. PRINTED COPIES OF THIS DOCUMENT ARE VALID FOR 24 HOURS.
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Each injury/illness should be recorded only once and categorized using the hierarchy on the following page. For example, a Lost-Time Injury that involves Medical Treatment and subsequent Restricted Work shall be categorized as a Lost-Time Injury. The Total Recordable Injury Frequency (TRIF) rate is to be calculated using the formula on the following page. Reports are to be submitted to the EPCOR Contract Coordinator and copied to the area EPCOR HS&E Advisor on 10th business day of the month.
Lost Days The number of calendar days that the employee is unable to work beyond the day of injury/illness recommended by a physician or other health care professional. Lost time ends as of the date that the employee is deemed fit to work either full or Restricted Work or to a maximum of 180 calendar days for any individual case. For cases where the disability will continue beyond the closing date, Lost Days and Restricted Days shall be estimated on the basis of medical opinion as to probable ultimate disability and included in the data submission. Lost Days are only recorded for the period that the injured person is in the employ of the company. Restricted Days The number of calendar days to a maximum of 180 days during which the employee is subject to Restricted Work, based on the recommendation of a physician or licensed health care professional, for an individual case. For cases where the disability will continue beyond the closing date, Lost Days and Restricted Days shall be estimated on the basis of medical opinion as to probable ultimate disability and included in the data submission. Restricted Days are only recorded for the period that the injured person is in the employ of the company. Exposure Hours Exposure to injuries shall be measured by the total number of hours of employment (i.e., the actual worked hours) of all employees for each contractor and sub-contractor companies for the reporting period. Total Recordable Injury Frequency Rate = Number of Recordable Injuries X 200,000 Total Exposure Hours
Current versions of controlled documents are posted on the EPCOR intranet. Versions obtained from other locations are considered uncontrolled. It is the users responsibility to verify that this is the current version. PRINTED COPIES OF THIS DOCUMENT ARE VALID FOR 24 HOURS.