Group/
S No Description Frequency Checklist SFW Closing Method Link
Individual
Role assignment office orders of HOP and No
1. SFW 130 KEY SAFETY ROLES APPOINTMENT 1 Year I NA
GM(O&M)s to be uploaded link
Resource list of disaster management
SFW 140 EMERGENCY MANAGEMENT INFRA No
2. 6 Month I NA equipment to be uploaded with its last
PM link
Preventive maintenance date
No
3. SFW 140 EMERGENCY PLAN AWARENESS TRNG 1 Year I NA Safety training record on DMP to be uploaded
link
No
4. SFW 140 PROJ EMERGENCY PLAN REVIEW 1 Year I NA Approved DMP to be uploaded
link
Mock drill schedule with report on observations No
5. SFW 140 PROJECT MOCK DRILL STATUS 6 Month I NA
to be uploaded link
Annual Safety Plan for project department wise No
6. SFW 150 PROJECT SAFETY PLANS STATUS 1 Year I NA
with progress % completion to be uploaded link
Training record of staff on new module or new No
7. SFW 160 O&M TRAINING BEFORE TAKEOVER 1 Year I NA
unit to be uploaded link
Table of identified maintenance process with No
8. SFW 160 SMPs STATUS 3 Years G NA
SMP nos to be uploaded link
Table of identified maintenance process with No
9. SFW 160 SOPs STATUS 3 Years G NA
SOP nos to be uploaded link
Table of equipment with specific isolation list No
10. SFW 160 SPECIFIC ISOLATION LIST STATUS 1 Year G NA
number to be uploaded link
Table of equipment with specific Job Plan No
11. SFW 160 SPECIFIC JOB PLANS STATUS 1 Year G NA
number to be uploaded link
Table of equipment with specific JSA to be No
12. SFW 160 SPECIFIC JSA AND MS STATUS 1 Year G NA
uploaded link
Final safety inspection prior to takeover to be No
13. SFW160 SAFETY CHECK BEFORE TAKEOVER 1 Year I NA
uploaded link
1 Year or No
14. SFW 210 PROJECT RISK MGMT HIRA REVIEW G NA Latest reviewed HIRA to be uploaded
any major link
accident, if
applicable
No
15. SFW 210 PROJECT TRAINING HIRA 6 monthly I NA Training record of HIRA program to be uploaded
link
SFW 210 WORKER TRAINING TOOL BOX At page
16. 1 Month G List of Toolbox Talk to be uploaded
TALKS no 4
Training records of workers on safe work
No
17. SFW 210 WORKERS TRAINING ON HAZARDS 1 Month G NA procedure/ Job specific training modules to be
link
uploaded
Table of plant modification during the period No
18. SFW 220 CHANGE MANAGEMENT HIRA REVIEW 3 Month I NA
with HIRA study its confirmation to be uploaded link
Training record of awareness of legal and No
19. SFW 230 INCIDENT REPORTING PROMOTION 3 Month I NA
incident reporting to be uploaded link
Training record of incident investigation No
20. SFW 230 TRAINING INCIDENT INVESTIGATORS 3 Month I NA
program to be uploaded link
Training record of awareness of legal and No
21. SFW 230 TRAINING INCIDENT REPORTING 1 Year I NA
incident reporting to be uploaded link
MOM of incident recall on meeting like safety No
22. SFW 240 CASE STUDIES ON INCIDENT RECALL 1 Month G NA
committee meeting to be uploaded link
At page List of incident based tool box talk shared with
23. SFW 240 INCIDENT RECALL TOOLBOX TALKS 1 Month G
no 5 workers to be uploaded
Legal register with compliance and NCs to be No
24. SFW 310 PROJECT LEGAL COMPLIANCE STATUS 1 Month G NA
uploaded link
Training record of legal awareness program to No
25. SFW 310 STAFF LEGAL AWARENESS TRAINING 3 Months I NA
be uploaded link
At page Department self audit schedule vs completed
26. SFW 320 DEPT SELF AUDIT STATUS 1 Month G no 6 and with list of NCs with completion target to be
7 uploaded
CFST Audit schedule vs completed with list of No
27. SFW 320 PROJECT CFST AUDIT STATUS 1 Month I NA
NCs with completion target to be uploaded link
External Audit schedule vs completed with list No
28. SFW 320 PROJECT EXTERNAL AUDIT STATUS 3 Months I NA
of NCs with completion target to be uploaded link
Internal Audit schedule vs completed with list of No
29. SFW 320 PROJECT INTERNAL AUDIT STATUS 3 Months I NA
NCs with completion target to be uploaded link
30.
SFW 320 STAFF INTERNAL AUDITOR 1 year I At page 8
Standard Training audit schedule and list of
TRAINING trained auditors to be uploaded
Health risk Audit schedule (like toilet, Pantry
No
31. SFW 330 HEALTH RISK INSPECTIONS STATUS 1 Month I NA inspection schedule) vs completed with list of
link
NCs with completion target to be uploaded
Status of plant simulation to be recorded.
No
32. SFW 340 OPERATIONAL SIMULATIONS STATUS 1 Week G NA Reason and authority for the simulation to be
link
explicitly mentioned
Contractor assessment schedule vs completed
SFW 360 CONTRACTOR SAFETY At page
33. 3 Months G with list of violations including at risks
ASSESSMENTS no 10
behaviour and action taken to be uploaded
Table that identifies risks and control measures
34.
SFW 360 CONTRACTS RISK CONTROL 3 Months G
At page
for all active contracts at site to be maintained
MATRIX no 11
reviewed periodically for adequacy of controls
SFW 411 WORKER ROLE COMPETENCE At page Training plan for role to be recorded and
35. 3 Months G
MATRIX no 12 uploaded
Annual staff safety and health competency and
No
36. SFW 412 EIC HOD REFRESHER TRAINING 6 months I NA improvement/ refresher training plan to be
link
uploaded
Annual worker safety and health competency
and improvement/ refresher training plan to be No
37. SFW 412 MASS WORKER SAFETY TRAINING 1 Year I NA
uploaded with record of topic attendees and link
trainer
List of all safety signages with their location and No
38. SFW 422 SAFETY SIGNAGE -------- I NA
no in plant to be attached link
No
39. SFW 422 VISITOR ACCESS CONTROL -------- I NA
link
List of incident and date of communication to No
40. SFW PROJECT INCIDENT REPORT CIRCULATION 1 Month I NA
staff/worker to be uploaded link
WORKER TRAINING TOOL BOX TALKS SAMPLE
SFW 210 Worker Training Tool Box Talks
NOTE: Cells are filled out in blue font for illustrative purposes only. Cells have comments embedded for further guidance.
The number of TBTs would vary depending on the function.
It is essential that you have a schedule, the numbers of activities are not important.
Comments are provided in some cells as further guidance - DO NOT DELETE THE COMMENTS.
SFW 210 WORKER TRAINING TOOL BOX TALKS (TBT) App text string C&I 21NOV TBT ORDER 1234564790
TBT SL NO. Work Description Order no. JSA No. TBT Topic / Work Given By Attendees REMARKS
2021NOV001 ST-II Silo-3 comm. cable to be check 100926774 Manual JSA Work at height/ Safety PPE Anoop K 3 Tool box talk on 28/11/2021
2021NOV002 Mill-6E CAD inoperative 202068165 C&I/JSA-03 Operating of hand tools (Calibrator, Spanner etc,)Abhay Bhattad 2 Tool box talk on 29/11/2021
2021NOV003 u *4 B GROUP WATER V CYLINDR ACTU PASSIN 105248769 C&I/JSA-05 Material handling of Cylinder Saji philip 3 Tool box talk on 29/11/2021
2021NOV004 4WK PM CHECKS U#5 ASH LEVEL SWITCHES 306170111 C&I/JSA-08 Electrical Safety Abhay Bhattad 2 Tool box talk on 29/11/2021
2021NOV005
2021NOV006
2021NOV007
2021NOV008
2021NOV009
2021NOV010
NOTE: TBT ATTENDENCE RECORD SHALL HAVE TBT SL NO. AS CROSS REFERENCE FOR EASY RETRIEVAL OF DATA
SFW 240 INCIDENT RECALL TOOLBOX TALKS SAMPLE
SFW 240 Incident Recall Toolbox Talks
NOTE: Cells are filled out in blue font for illustrative purposes only. Cells have comments embedded for further guidance.
The number of TBTs would vary depending on the function.
It is essential that you have a schedule, the numbers of activities are not important.
Comments are provided in some cells as further guidance - DO NOT DELETE THE COMMENTS.
SFW 240 Incident Recall Toolbox Talks App text string EMD 21NOV INCIDENT RECALL TBT
Serial # Incident Notification Number Topic Given By Attendees REMARKS
Fatal Fall from height - not paying attention to
2021NOV001 1234567890 Anoop K 15 Talk given on 28/11/2021
platform condition
2021NOV002
2021NOV003
2021NOV004
2021NOV005
2021NOV006
2021NOV007
2021NOV008
2021NOV009
2021NOV010
NOTE: ATTENDENCE RECORD SHALL HAVE TBT SL NO. AS CROSS REFERENCE FOR EASY RETRIEVAL OF DATA
DEPT SELF AUDIT STATUS SAMPLE
SFW 322 DEPT SELF ASSESSMENT
AREA ENGINEER OR PERSON ACCOUNTABLE FOR AN AREA/TYPE OF WORK
NOTE: Cells are filled out in blue font for illustrative purposes only. Cells have comments embedded for further guidance.
The number of activities would vary depending on your role at the location.
It is essential that you have a schedule, the numbers of activities are not important.
Comments are provided in some cells as further guidance - DO NOT DELETE THE COMMENTS.
Yellow filled cells are for you to decide & fill. Depending on your individual responsibility & accountability.
Name of
# Monday Tuesday Wednesday Thursday Friday Saturday % Completed
Employee
AREA
TBT talk against high TBT talk against high TBT talk against high risk TBT talk against high TBT talk against high TBT talk against high
risk work order risk work order work order risk work order risk work order risk work order
Contractor T&P checking
JSA & PPE compliance JSA & PPE compliance JSA & PPE compliance
for valid certificates, Tool boxes, gas cutting Housekeeping & First-
1 A checks, Worker checks, Worker checks, Worker
ELCB, hand lamp guards, set & welding sets checks Aid Box checks
awareness of Hazards awareness of Hazards awareness of Hazards
etc.
JSA & PPE compliance JSA & PPE compliance
as assigned by as assigned by Ladders & scaffold as assigned by
checks, Worker checks, Worker awareness
HOD/HOS HOD/HOS material checks HOD/HOS
awareness of Hazards of Hazards
Worker Std Module as assigned by as assigned by as assigned by Worker Std Module
Housekeeping checks
Training HOD/HOS HOD/HOS HOD/HOS Training
AREA
2 B
AREA
3 C
AREA
4 D
DEPT SELF-ASSESSMENT HOD - HOS
NOTE: Cells are filled out in blue font for illustrative purposes only. Cells have comments embedded for further guidance.
The number of activities would vary depending on your role at the location.
It is essential that you have a schedule, the numbers of activities are not important.
Comments are provided in some cells as further guidance - DO NOT DELETE THE COMMENTS.
Yellow filled cells are for you to decide & fill. Depending on your individual responsibility & accountability.
Month Week #1 Week #2 Week #3 Week #4 % Completed
FOCUS AREA
Check: PTW+JSA+PPE Compliance, Check: PTW+JSA+PPE Compliance, Check: PTW+JSA+PPE Compliance, Check: PTW+JSA+PPE Compliance, Worker Hazard
Worker Hazard Awareness Worker Hazard Awareness Worker Hazard Awareness Awareness
Random checks for Contractor Tools,
Jan ANNUAL REVIEW - Legal Register
Vehicles, Equipment, Cranes, etc.
MONTHLY - INCIDENT SHARING - MONTHLY - INCIDENT SHARING - MONTHLY REVIEW - TOOL BOX MONTHLY - MASS PEP TALK (as per schedule
STAFF WORKERS TALKS STATUS & RECORDS circulated by Safety Dept) & FIRST AID BOX check
MONTHLY - Update CONTRACTOR performance
Risk Control Matrix
REVIEW - AREA ENGINEERS activity REVIEW - AREA ENGINEERS activity REVIEW - AREA ENGINEERS activity REVIEW - AREA ENGINEERS activity compliance
compliance with schedule compliance with schedule compliance with schedule with schedule
REVIEW - Housekeeping, Scrap REVIEW - Housekeeping, Scrap REVIEW - Housekeeping, Scrap REVIEW - Housekeeping, Scrap segregation &
segregation & disposal. segregation & disposal. segregation & disposal. disposal.
FOCUS AREA ANNUAL REVIEW - CONTRACTS with Staff
Check: PTW+JSA+PPE Compliance, Check: PTW+JSA+PPE Compliance, Check: PTW+JSA+PPE Compliance, Check: PTW+JSA+PPE Compliance, Worker Hazard
Worker Hazard Awareness Worker Hazard Awareness Worker Hazard Awareness Awareness
Random checks for Contractor Tools,
Feb
Vehicles, Equipment, Cranes, etc.
MONTHLY - Update CONTRACTOR performance
Risk Control Matrix
MONTHLY - INCIDENT SHARING - MONTHLY - INCIDENT SHARING - MONTHLY REVIEW - TOOL BOX MONTHLY - MASS PEP TALK (as per schedule
STAFF WORKERS TALKS STATUS & RECORDS circulated by Safety Dept) & FIRST AID BOX check
REVIEW - AREA ENGINEERS activity REVIEW - AREA ENGINEERS activity REVIEW - AREA ENGINEERS activity REVIEW - AREA ENGINEERS activity compliance
compliance with schedule compliance with schedule compliance with schedule with schedule
REVIEW - Housekeeping, Scrap REVIEW - Housekeeping, Scrap REVIEW - Housekeeping, Scrap REVIEW - Housekeeping, Scrap segregation &
segregation & disposal. segregation & disposal. segregation & disposal. disposal.
FOCUS AREA
Check: PTW+JSA+PPE Compliance, Check: PTW+JSA+PPE Compliance, Check: PTW+JSA+PPE Compliance, Check: PTW+JSA+PPE Compliance, Worker Hazard
Worker Hazard Awareness Worker Hazard Awareness Worker Hazard Awareness Awareness
Random checks for Contractor Tools,
Mar
Vehicles, Equipment, Cranes, etc.
QUARTERLY - Update CONTRACTOR performance
Risk Control Matrix
STAFF INTERNAL AUDITOR TRAINING SAMPLE
CONTRACTOR SAFETY RISK CONTROL
SFW 360 Contractor Risk Control - DEPT NAME QUARTER 2021 Q2
PO NO 4000253634 Item-110
PO VALIDITY 01.02.2021 - 31.01.2023
CONTRACTOR NAME M/s UTILITY POWERTECH LTD
Periodical Maint. Works in EM in Main Plant & Offsite Areas for the year 2020-
NAME OF WORK
22
# Safety Plan July Remarks Aug Remarks Sep Remarks
1 Legal Compliance Complied
1.1 PF/ESI/Insurance PF & ESI complied HR NOC certificate
2 Mobilization Mobilised as per contract
2.1 Workers (Expected/Actual) Deployed as per contract CLIMS login
Confirmed skill set of workers as Skilled -1, Semiskilled-02 ,
2.2 Workers Skill Level (Expected/Actual)
mentioned in the contract. Unskilled -23 nos
2.3 Tools (Expected/Actual) Deployed as per contract
3 Safety Compliance Not specified in the contract
3.1 PPE Not specified in the contract
3.2 Unsafe Behavior - Penal Action Taken Not specified in the contract
4 Number of Safety Violations Complied
4.1 Number of Safety Penalty Imposed Complied Signed copy
4.2 JSA Implementation Compliance Complied
4.3 Workers Health Check-Up Compliance Records Complied
4.4 OSH Training Given To Workers Nil
4.5 Competent First Aider Complied
Complied health check up done as per Ensured health check up prior to
5 CLIMS Compliance
statutory requirement issuing gate passes
Pep talks: 1 Workers: 26.
6 OSH training given to workers
Tool box talks: 23 Workers: 115.
7 Competent First Aider Not specified in the contract
Gate pass issued after CLIMS
8 CLIMS COMPLIANCE Complied
requirement compliance
EIC SIGNATURE
9
(scan signed paper, or sign digitally)
NOTE:
1 BLUE TEXT - is for ILLUSTRATIVE PURPOSES ONLY
2 HOD/HOS can consolidate all Contracts under him/her, or ask respective EICs to prepare the same in individual PDF files, combine them in 1 PDF file to demonstrate compliance.
3 HOD/HOS to upload only 1 conslidated PDF file to demonstrate compliance.
CONTRACTOR SAFETY ASSESSMENT SAMPLE
Worker Role Competence SAMPLE
