FORM E

ENTITY QUARTERLY OHS PERFORMANCE REPORT

General Information
Classification Code:

Registration Number:

Name of Entity:

EHSMS Approval Date:

Address of Entity:

Telephone Number
Name:

Contact Details of EHS

Focal Point:

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)

Reporting Timeframe:

Q2 (Apr-Jun)

Mid April

Mid July

Q3 (Jul-Sep)

Q4 (Oct-Dec)

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

Lost Time
Injuries

No.

Lost
Workdays

Other Incidents

Fatality

Serious
Occurrence

Permanent Total Disability

Equipment
Damage

l
No.

Dangerous
/

Property

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)]

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

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 Total Injuries &

Illness Reported in the
Reporting Period

Number of
Working Hours in
Reporting Period

TRC
x 1,000,000
Working Hours

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

Number of Lost Time

Injuries in the Reporting
Period

Number of
Working Hours in
Reporting Period

AD EHSMS RF Form E - Version 2.1 - December 2013

Working Hours

No. of LTIs x 1,000,000

Working Hours

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FORM E
ENTITY QUARTERLY OHS PERFORMANCE REPORT
Near Miss

KPI 2-06

First Aid Cases

Number of Near Miss & First Aid Cases for Entity:

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
Injuries & Illness

Total Incidents /Consequences

Other Incidents

No.

No.

Fatality

Serious Dangerous Occurrence

Permanent Total Disability

Equipment / Property Damage

Permanent Partial Disability

Lost Time Injuries

Lost Workdays Cases

a)

Lost Workdays Injuries

b)

Lost Workdays
Illness

Occupational

Restricted Workday Case

Medical Treatment Case
Near Miss

KPI 3-02

First Aid Cases

Number of Near Miss & First Aid Cases for Contractors:

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.)
Total Incidents (Fatalities & Injuries)
KPI 4-01
Number of Fatalities & Injuries for other Persons:

KPI 4-02

Fatality

Other Injuries

Near Miss

First Aid Cases

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

EHS Resources, EHSMS Development, Implementation and Enforcement Summary for Entity
Number of Employees in EHS
Department

Number of UAE Nationals in

EHS Department

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

KPI 5-01
Department Resources

KPI 5-02
Average Number of
Training Hours per
Employee

Number of Employees
attended the AD EHSMS
Practitioner Course

Number of OHS
Training Hours
Undertaken

Number of Employees Registered at Qudorat

No. of OHS Training Hours undertaken by Employees

Total No. of Employees

rd

KPI 5-03

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

Third Party EHSMS Compliance Audit

EHSMS Compliance Audit is scheduled for (insert date)

AD EHSMS RF Form E - Version 2.1 - December 2013

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FORM E
ENTITY QUARTERLY OHS PERFORMANCE REPORT
KPI 5-04

Number of warning notices received:

Number of Corrective Notices (warning notices,

improvement notices) received from the SRA as a
result of non-compliance to EHSMS requirements

Number of improvement notices received:

KPI 5-05

Number of fines / penalties received:

Number of Breach Notices (fines / penalties /

enforceable undertakings) received from the SRA
as a result of non-compliance to EHSMS
requirements

Number of enforceable undertakings (entitys commitment

to spend money to rectify EHSMS non- compliance):

Number of prohibition notices received:

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):

Date :

Official
Stamp:

Official Use
Remarks :

Relevant Authority Stamp

Entered into Database by:

Name:
Signature:
Date:

__ / __ / ____

Reviewed by:
Name:
Signature:
Date:

AD EHSMS RF Form E - Version 2.1 - December 2013

__/ __/ ____

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