FORM E ENTITY QUARTERLY OHS PERFORMANCE REPORT

AD EHSMS RF Form E - Version 2.1 - December 2013 Page 1 of 3

General Information

Classification Code: Registration Number:

Name of Entity: EHSMS Approval Date:

Address of Entity: Telephone Number

Contact Details of EHS Focal Point:

Name:

E-mail: Telephone Number

Number of Employees: Working Hours Performed this Quarter*

*Working Hrs. = No. of employees x working hrs. x No. of workdays (This simple formula is to be used only if no accurate mechanism available)

Reporting Period: Year: ___

Q1 (Jan-Mar) Q2 (Apr-Jun) Q3 (Jul-Sep) Q4 (Oct-Dec) Reporting Timeframe: Mid April Mid July Mid October Mid-January

Occupational Health & Safety Performance Mandatory Reporting to Sector Regulatory Authority Note: Refer to AD EHSMS RF Mechanism 6.0 (a) Section 4.4 for reporting of incident with multiple consequences, and (b) Schedule B & C for Guidance on Injuries & Illness

Occupational Health & Safety Performance Summary for Entity, Contractors & Other Persons KPI 2-01 Total Incidents (sum of KPI 2-02, 3-01 & 4-01)

Occupational Health & Safety Performance Summary for Entity KPI 2-02 Total Incidents / Consequences

Injuries & Illness No. Lost Workdays Other Incidents No.

Lost Time Injuries

Fatality Serious Dangerous Occurrence

Permanent Total Disability Equipment / Property Damage

Permanent Partial Disability

Lost Workdays Cases

a) Lost Workdays Injuries

b) Lost Workdays Occupational Illness

Restricted Workday Case

Medical Treatment Case

Total Injuries & Illness for calculating KPI 2-03 (TRCF)

Total Lost Workdays for calculating KPI 2-04 (LTISR)

KPI 2-03 Total Reported Case Frequency (TRCF) [Total Injuries & illness reported in KPI 2-02 (Lost Time Injuries, Restricted Workdays and Medical Treatment Cases)]

Number of Total Injuries & Illness Reported in the

Reporting Period

Number of Working Hours in Reporting Period

TRC x 1,000,000 Working Hours

KPI 2-04 Lost Time Injury Severity Rate (LTISR) [Total Lost Workdays reported in KPI 2-02] Zero LWDs for Fatality & Permanent Total Disability

Number of Workdays lost due to Injuries & illness in

the Reporting Period

Number of Working Hours in Reporting Period

No. of Days Lost x 1,000,000 Working Hours

KPI 2-05 Lost Time Injury Frequency Rate (LTIFR) [Total Lost Time Injuries reported in KPI 2-02 (Fatality, Permanent Total Disability, Permanent Partial Disability & Lost Workdays Cases)]

Number of Lost Time Injuries in the Reporting

Period

Number of Working Hours in Reporting Period

No. of LTIs x 1,000,000 Working Hours

KPI 2-06 Number of Near Miss & First Aid Cases for Entity:

Near Miss First Aid Cases

FORM E ENTITY QUARTERLY OHS PERFORMANCE REPORT

AD EHSMS RF Form E - Version 2.1 - December 2013 Page 2 of 3

Occupational Health & Safety Performance Summary for Contractors (hired by or working for Entity but not Nominated currently with any concerned SRA/does not fall under any current Sector). KPI 3-01 Total Incidents / Consequences

Injuries & Illness No. Other Incidents No.

Lost Time Injuries

Fatality Serious Dangerous Occurrence

Permanent Total Disability Equipment / Property Damage

Permanent Partial Disability

Lost Workdays Cases

a) Lost Workdays Injuries

b) Lost Workdays Occupational Illness

Restricted Workday Case

Medical Treatment Case

KPI 3-02 Number of Near Miss & First Aid Cases for Contractors:

Near Miss First Aid Cases

KPI 3-03 Number of Monitoring Activities Performed on Contractor(s) / Supply Chain by Entity:

Total No. of Contractors Inspections Performed on Contractors

Review / Approval of Contractor EHS Procedures. Contractor Incidents Investigated by Entity.

Specific Requirement / Part System Audit Performed on Contractors Corrective Notices Issued to Contractors:

Full EHSMS Audit Performed on Contractor Breach Notices Issued to Contractors:

Incident Summary for Other Persons (Visitors, Students, Hotel Guests, Passengers, etc.)

KPI 4-01 Number of Fatalities & Injuries for other Persons:

Total Incidents (Fatalities & Injuries)

Fatality Other Injuries

KPI 4-02 Number of Near-Miss & First Aid Cases for other Persons:

Near Miss First Aid Cases

EHS Resources, EHSMS Development, Implementation and Enforcement Summary for Entity

KPI 5-01 Department Resources

Number of Employees in EHS Department

Number of UAE Nationals in EHS Department

No. of Nationals x 100 No. of Employees in EHS Dept.

Number of Employees attended the AD EHSMS

Practitioner Course Number of Employees Registered at Qudorat

KPI 5-02 Average Number of Training Hours per Employee

Number of OHS Training Hours

Undertaken

No. of OHS Training Hours undertaken by Employees Total No. of Employees

KPI 5-03 Third Party EHSMS Compliance Audit

3rd Party EHSMS Compliance Audit conducted and Audit Report submitted to SRA

EHSMS Compliance Audit is scheduled for (insert date)

KPI 5-04 Number of Corrective Notices (warning notices, improvement notices) received from the SRA as a result of non-compliance to EHSMS requirements

Number of warning notices received:

Number of improvement notices received:

Number of prohibition notices received:

FORM E ENTITY QUARTERLY OHS PERFORMANCE REPORT

AD EHSMS RF Form E - Version 2.1 - December 2013 Page 3 of 3

KPI 5-05 Number of Breach Notices (fines / penalties / enforceable undertakings) received from the SRA as a result of non-compliance to EHSMS requirements

Number of fines / penalties received:

Number of enforceable undertakings (entitys commitment to spend money to rectify EHSMS non- compliance):

Total value of all fines / penalties/ enforceable undertakings enforced (AED):

Declaration

I declare that all information provided in this document is true, correct and complete.

Signature of the CEO / MD: (Top Manager):

Official Stamp:

Date : _____ / _____ / _____

Official Use Remarks :

Relevant Authority Stamp Entered into Database by:

Name:

Signature:

Date: _____ / _____ / _____

Reviewed by: Name:

Signature:

Date: _____ / _____ / _____

General InformationInjuries & Illness No.No.Injuries & Illness No.No.KPI 5-04KPI 5-05DeclarationOfficial Use

Relevant Authority Stamp

Classification Code: Registration Number: Name of Entity: EHSMS Approval Date: Address of Entity: Telephone Number: Name: Email: Telephone Number_2: Number of Employees: Working Hours Performed this Quarter: Q1 JanMar: Q2 AprJun: Q3 JulSep: Q4 OctDec: KPI 201 Total Incidents sum of KPI 202 301 401: KPI 202 Total Incidents Consequences: NoFatality: NoSerious Dangerous Occurrence: NoPermanent Total Disability: NoEquipment Property Damage: NoPermanent Partial Disability: a Lost Workdays Injuries: b Lost Workdays Occupational Illness: Medical Treatment Case: Total Injuries Illness for calculating KPI 203 TRCF: Number of Total Injuries Illness Reported in the Reporting PeriodKPI 203 Total Reported Case Frequency TRCF Total Injuries illness reported in KPI 202 Lost Time Injuries Restricted Workdays and Medical Treatment Cases: Number of Working Hours in Reporting PeriodKPI 203 Total Reported Case Frequency TRCF Total Injuries illness reported in KPI 202 Lost Time Injuries Restricted Workdays and Medical Treatment Cases: TRC x 1000000 Working HoursKPI 203 Total Reported Case Frequency TRCF Total Injuries illness reported in KPI 202 Lost Time Injuries Restricted Workdays and Medical Treatment Cases: Number of Workdays lost due to Injuries illness in the Reporting PeriodKPI 204 Lost Time Injury Severity Rate LTISR Total Lost Workdays reported in KPI 202 Zero LWDs for Fatality Permanent Total Disability: Number of Working Hours in Reporting PeriodKPI 204 Lost Time Injury Severity Rate LTISR Total Lost Workdays reported in KPI 202 Zero LWDs for Fatality Permanent Total Disability: No of Days Lost x 1000000 Working HoursKPI 204 Lost Time Injury Severity Rate LTISR Total Lost Workdays reported in KPI 202 Zero LWDs for Fatality Permanent Total Disability: Number of Lost Time Injuries in the Reporting PeriodKPI 205 Lost Time Injury Frequency Rate LTIFR Total Lost Time Injuries reported in KPI 202 Fatality Permanent Total Disability Permanent Partial Disability Lost Workdays Cases: Number of Working Hours in Reporting PeriodKPI 205 Lost Time Injury Frequency Rate LTIFR Total Lost Time Injuries reported in KPI 202 Fatality Permanent Total Disability Permanent Partial Disability Lost Workdays Cases: No of LTIs x 1000000 Working HoursKPI 205 Lost Time Injury Frequency Rate LTIFR Total Lost Time Injuries reported in KPI 202 Fatality Permanent Total Disability Permanent Partial Disability Lost Workdays Cases: Near MissKPI 206 Number of Near Miss First Aid Cases for Entity: First Aid CasesKPI 206 Number of Near Miss First Aid Cases for Entity: KPI 301 Total Incidents Consequences: NoFatality_2: NoSerious Dangerous Occurrence_2: NoPermanent Total Disability_2: NoEquipment Property Damage_2: NoPermanent Partial Disability_2: a Lost Workdays Injuries_2: b Lost Workdays Occupational Illness_2: Restricted Workday Case_2: Medical Treatment Case_2: Near MissKPI 302 Number of Near Miss First Aid Cases for Contractors: First Aid CasesKPI 302 Number of Near Miss First Aid Cases for Contractors: Total No of Contractors: Inspections Performed on Contractors: Review Approval of Contractor EHS Procedures: Contractor Incidents Investigated by Entity: Specific Requirement Part System Audit Performed on Contractors: Corrective Notices Issued to Contractors: Full EHSMS Audit Performed on Contractor: Breach Notices Issued to Contractors: FatalityKPI 401 Number of Fatalities Injuries for other Persons: Other InjuriesKPI 401 Number of Fatalities Injuries for other Persons: Near MissKPI 402 Number of NearMiss First Aid Cases for other Persons: First Aid CasesKPI 402 Number of NearMiss First Aid Cases for other Persons: Number of Employees in EHS DepartmentKPI 501 Department Resources: Number of UAE Nationals in EHS DepartmentKPI 501 Department Resources: No of Nationals x 100 No of Employees in EHS DeptKPI 501 Department Resources: Number of Employees attended the AD EHSMS Practitioner CourseKPI 501 Department Resources: Number of Employees Registered at QudoratKPI 501 Department Resources: Number of OHS Training Hours UndertakenKPI 502 Average Number of Training Hours per Employee: No of OHS Training Hours undertaken by Employees Total No of EmployeesKPI 502 Average Number of Training Hours per Employee: 3rd Party EHSMS Compliance Audit conducted and Audit Report submitted to SRA: EHSMS Compliance Audit is scheduled for insert date: Number of warning notices received: Number of improvement notices received: Number of prohibition notices received: Number of fines penalties received: Number of enforceable undertakings entitys commitment to spend money to rectify EHSMS noncompliance: Total value of all fines penalties enforceable undertakings enforced AED: Signature of the CEO MD Top Manager: Official Stamp: undefined: undefined_2: undefined_3: Remarks: Relevant Authority StampRow1: Name_2: Signature: undefined_4: undefined_5: undefined_6: Name_3: Signature_2: undefined_7: undefined_8: undefined_9: Total Incidents Fatalities Injuries: Text1: Text2: Text3: Text4: Text5: Restricted Workday Case: