Hse-34 Staff Competency Assessment Form

STAFF COMPETENCY ASSESSMENT Doc Ref # GCL/F/IMS/HSE/34
CHECKLIST – HEALTH & SAFETY

REV # 01
Effective date # 01.09.2022
Project Name
Employee Name Designation
Department Assessment Date
Ref. Discussion Topic & Activities as per Scope of Role Competency Verified Date to
complete
Follow up action or
Yes No N/A comments
Safety Policy: Does the staff member understand the
1 policy?
Rights: Does the staff member know the three basic

worker rights?
 Right to know hazards in the workplace
2  Right to participate in health and safety in the
workplace,
Right to refuse of unsafe work
Safety Responsibilities: Is the staff member familiar
3 with the safety manual and can locate and understands
the roles and responsibilities and procedures?
Identifying and Reporting Hazards, Unsafe
4 Conditions/Acts: Does the staff member know the
approach to identify hazards and unsafe
conditions/acts and their duty to report? Understands
Violence in the Workplace expectations including
security, reporting violence or threat of
violence ,Bullying and Harassment
 Recognize/Report it
 Assess it
Control it (see below)
Personal Protective Equipment Does the staff
member understand:
5  What PPE is required for the job?
 Where to obtain?
 PPE care and maintenance
When PPE must be replaced? e.g. hardhats, boot
TASK Briefing: Does the staff member understand
6 the purpose of the meetings and their duty for attending
and actively participating?
Training Requirements: Does the staff member know
what training is required for their job? Have they
received the appropriate training?
7
Safe Work Practices Monitoring: Has the supervisor
8 monitored the staff member at the work site to observe
the member’s attitude and safety practices while
performing regular job functions and documented?
Have any deficiencies been addressed?
Page 1 of 3
REV # 01
Incidents, Accidents and close calls: Does the staff

9 member understand what is required of them when
they experience an incident, accident or close call?
Does the staff member understand the purpose of
investigations and how they may be involved?
Sub-Contractors: Does the staff member understand
10 their responsibilities when dealing with sub contracts
with respect to Safety Program requirements?
Emergency Response: Does the staff member know
11 the Emergency Response Plan, First Aid and
Evacuation Procedures. Do they know their
responsibilities in the event of an emergency?
Safe Work Procedure of Excavation: Does the staff
12 member know the safe work procedure?
 Hazards, Risk Assessment, Control Measure.
DM standards, Underground Utilities
Traffic Management, Road Safety & Diversions
Does the staff aware of controlled traffic on site?
Do he/she understand traffic rules?
13 Hazards, Risk Assessment, Control Measure?
1411 Safe Work Procedure of Lifting: Does the staff
member know the safe lifting procedure?
Hazards, Risk Assessment, Control Measure
Does the staff member aware of Safe Lifting procedure
14 of Palm Trees?
Safety procedures, Inspections of Lifting Accessories?
Use of Equipment intended for the purpose?
Training and Competence of operator?
Equipment Maintenance Records?
Welfare Facilities:
15 Do the staffs understand basic welfare requirements
and its provision?
Maintaining Welfare arrangements?
First Aid Requirement, Rest Rooms, Summer safety
Procedures?
Legal Requirements?
Additional Safety Issues Covered:
Person Conducting Evaluation:

Name Designation
Date Signature
Staff Member Competence Assessed:
Page 2 of 3
REV # 01
Name Designation
Date Signature
Acknowledgment:
I, _____________________________________ representing, Gulf Contracting & Landscaping LLC in capacity of Project
Manager, have assigned _______________________________ in capacity of _____________________________to be the
competent person in the areas indicated and I acknowledge that this individual has been thoroughly trained and is
experienced in hazard recognition and has the authority to stop work and correct hazards in the event of a potential
hazardous or imminent danger situation.
_________________________________________ ____________________
Signature
Date
I, _________________________________________ acknowledge that I have been thoroughly trained and have the
experience to perform the duties as ________________________________ competent in the areas marked below.
I understand that I have the responsibility and authority to correct hazards and to stop work in the event of a potential
hazardous or imminent danger situation.
_________________________________________ ____________________
Signature
Date
Check previous training completed
Site Rules and Induction Legal Obligation Welding/Cutting-Hot Work
Personnel Protective
Equipment Method Statements Rigging
Lifting Operations Electrical Equipment Management
Housekeeping Ladders Excavations/Trenches
Demolition Risk Assessment First Aid/CPR
Hardscape and Soft cape Act. Material/Personnel Hoists Concrete/Shuttering
Material Storage and Handling Traffic Management Irrigation Activities
Consultant Recommendation: _________________________________________________________________

__________________________________________________________________________
Page 3 of 3

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STAFF COMPETENCY ASSESSMENT Doc Ref # GCL/F/IMS/HSE/34

CHECKLIST – HEALTH & SAFETY

Rights: Does the staff member know the three basic

Incidents, Accidents and close calls: Does the staff

Person Conducting Evaluation:

Staff Member Competence Assessed:

Consultant Recommendation: _________________________________________________________________

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