Protocol Format
Ref No: Works/safety/Doc No-01/Rev-00 Date: 06.03.2021
i) Title of Work:
ii) Nature of Work:
iii) Duration of Job with time:
iv) Name of Coordinators: a)Chief Coordinators with Designation and mobile no.:
b) Coordinators with Designation and mobile no.:
v) Name of person in-charge for execution of the work/Executing Authority with Designation and
mobile no:
vi) Executing Agency: a) Name of Department:
b) Name of Contractors (If involved) with mobile no.:
vii) Preparatory jobs:
Sl. No. List of Jobs Department Responsible Person
with designation and
mobile no.
viii) List of Safety provisions and facilities:
Sl.No. List of safety facilities Responsible Person
with designation and
mobile no.
ix) Sequence of job activities:
Sl.No. Sequence of Jobs Tentative Time Responsible Person
Duration with designation and
mobile no.
x) List of Safety Precaution:
Sl.No. List of Safety Precautions Name of responsible person
for compliance with designation
and mobile no.
xi) Sketch or schematic diagram of the location and its affected portion/section:
xii) Signature:
I) Executing Agency 2)Maintenance Agency 3)DSO 4)Safety Officer 5)Fire Engineering/Cisf
6)EMD 7)HOD of Concern Dept. 8) HOD of other involved/affected Dept.
9) HOD of Safety 10) Signature of Divisional Head/Head of Plant (if work involve larger area or
the entire plant)
