Project___________________________ Date

Make Year Vehicle Number

Location
initial check Re-check
If any Items red (requires repair),vehicle should not be used.
Contract equipment for assistance. S R X S R X

Local Applicable Equipment(Seat Belt ,first aid kit, fire extinguishers,

reflectors, load binders)

Visual inspection equipment of Vehicle, Including condition of all

tires, including spare (tread depth and pressure) and general
condition of vehicle.

Under hood Visual Inspection, Fluid levels, belts

Windshield, all windows and exteriors light lens, cleanliness and

visibility all lights operational, including headlights, spotlights,
tailing lights, turn signals, four way flasher, running clearance,
back-up lights(verify headlights regularity)

Hood ,Trunk, Gas cap secured

Vehicle Registration, insurance Card

Door Latches secure

Windshield wipers and washers optional

Instrument panel and Warning lights

Sun visors

Clime control and window defogger optional

Mirrors and Seat adjusted for drive

Service and parking breaks optional

Interior of vehicle clean and free of loose items and debris ; cargo
(if applicable) secured

Seat belt and/or shoulder harness optional

Head Restraint properly adjusted.

Horn and back up alarm

 Full size spare tires

360 Walk -around before vehicle movement

Steering is true, works and is correctly aligned. If vehicle does not

steer correctly or steering feels vague stop vehicle at safe place
and call equipment for assistance.

(S) Inspected and Satisfactory ( R ) REPAIRED OR ADJUSTED (X) REQUIRES REPAIR

COMMENTS

Contractor: ___ ______________________ Start Date: _______ End Date: _______

 Mobilization ES&H Checklist
As a minimum, the contractor prior to work beginning at Site will confirm the following items:
# Item Yes No N/A
1 Zero Accident Philosophy

2 Acceptance of working to project ES&H Program

3 Job Scope Risk Assessment & Method statement for Review and site
signoff (Hazard Assessment for Overall Work Activities)

4 Detailed JSA’s for each phase of work activities identified in job scope
JSA, e.g. Mobilization Activities, Offloading Procedures, Material
Handling, Temporary Facilities, etc. Require review and site sign-off.

5 Proof of Inspection/ Certification for the following Equipment:

6 Equipment
 Condition inspection ____ ____ ____
 Daily inspection ____ ____ ____
 Speed limit ____ ____ ____
 Seat belt ____ ____ ____
 Phones ____ ____ ____
 Maintenance ____ ____ ____
 Overloading ____ ____ ____
____ ____ ____
 Weigh Bridge/Scale Readings
____ ____ ____
 Working Hours
____ ____ ____
 Trained Drivers only to drive/Replacements must be trained
7 Training :
 Mobilization days ____ ____ ____
 Training requirements ____ ____ ____
 NO work before training and sign off from training department ____ ____ ____
to construction ____ ____ ____
 Spotters/Flagmen - no feet on ground ____ ____ ____

8 Medical/Emergency Response Plan including Emergency Contact

Names, Emergency Phone Numbers, etc.
9 The pre- mobilization kick-off will, at a minimum, review and discuss
the following:
 HSE meeting schedule establishment....... ____ ____ ____
 Reporting requirements............................................................... ____ ____ ____
 Emergency response ____ ____ ____
 Awareness of other work scopes................................................. ____ ____ ____
 STARRT/ JSA ____ ____ ____
 Site vehicle requirements i.e. Lights/Speed............... ____ ____ ____
 PPE ................................................... ____ ____ ____
____ ____ ____
 Red/Yellow Card - Incentive
____ ____ ____
____ ____ ____
 Unanticipated discoveries/ UXO / Archaeological Site
____ ____ ____
locations………………………………………………………………
____ ____ ____
____ ____ ____
____ ____ ____

10 Environmental
The following to be addressed:

 Spill Response ____ ____ ____

 Env. Awareness Training ____ ____ ____
 Erosion Control ____ ____ ____
  Reporting ____ ____ ____
 Drip Trays ____ ____ ____
 ____ ____ ____

11 Alcohol & Drugs

Zero Tolerance to Alcohol and Drugs. Random testing will be carried
out. Anything above 0.00 will result in revoking site access

All required information has been reviewed and meets the requirements set out in this
document:

Arber Dogani Designate

_______________ _____________ __________ _____________

Name Designation Signature Date

All required information has been reviewed and does not meet the requirements set out in this
document:

Designate

_Arber Dogani______________

Name Designation Signature Date

 _______________________ ___________________ _________________

Contractor Name Signature Date

ATTACHMENT 1

HSE Tour Report

Date: Project Section: Project KM / Work Area:

Time:

Locations:

Work taking place:

Document Reference - Method Statements, Permits etc.:

Tour Team:

Rate each subject using 0 – lowest to 10 – highest using compliance checklists:

Score System: 0 – 10 Rating

0 10 Score System: 0 – 10 Rating 0 10

No. Score No. Subject Score

Subject
 1 Waste Management 14 Night Working

2 Fuel Storage 15 Work on or Near Water

3 Water Quality 16 Traffic Management

4 Dust Control 17 Barricades and Fencing

5 Noise Control 18 Utilities and Buried Services

6 Scaffolding 19 Hot Works

7 Electricity 20 Lifting Operations

8 Plant and Machinery 21 Tools and Equipment

9 Fire Prevention 22 Excavations

10 Confined Spaces 23 Welfare

11 Fall Protection 24 Skin

12 PPE 25 Vibration

13 Housekeeping 26 Manual Handling

Subject Hazard
No: Actions requiring conformation of closeout Closeout Date/Signature
No. Rating

1.

2.

3.

Comments:

Hazard rating A -Immediately B – Within 24 hrs C – Time to be agreed X- Work to cease

Compliance Rating = (Total Score ( ) / Total Number of Items observed ( ) x 10) x 100 = %
Photo 1: Photo 2:
Photo 3: Photo 4:
 EYES ON SAFETY
TARGET ZERO

Your commitment to safety is a critical component in making the workplace safe and driving
toward zero accidents. Be aware of potential unsafe conditions and acts in our workplace, and
when you identify one, report it.

Use the card below to report unsafe acts and conditions or to recognize someone practicing safe
behaviors.

Project Area:

i.e. Section 1, 2,3,4

KM 1+200

Location:

i.e. Structure, KM Marker,

Crusher, Camp

Description:

 Unsafe act
 Unsafe condition

I caught someone
working safely:

 Safe behavior
Did you take corrective
action?

If yes, what was the

result?

If no, thank you for

reporting this issue.
We will follow up.

Was the unsafe act or

condition reported to a
supervisor?

Name

Employee #

Department

Thank you for completing this card. Now hand the card to your Supervisor, ES&H Supervisor, or
place in one of the boxes provided in your area or camp dining facility.

If you wish to receive feed back or be eligible for one of 2 prizes for the best 15 cards each month
please enter your name, employee number and department below.
Submitted by:

(Name optional)

This section to be completed by Office Safety

Corrective actions taken:
Corrective actions
complete

Tracking
Date:
No.

EYES ON SAFETY

TARGET ZERO
 Mase Disiplinore
Date :

Vend Ndodhje : Supervizor:

Ekipi :

Pershkrim i shkeljes.

Masa Disiplinore : Verejtje Para Lajmerim Perjashtim

Supervizori Emer Mbiemer

Shkelesi Emer Mbiemer

Data :
 Mase Disiplinore
Kjo mase disiplinore jepet per arsye te shkeljeve te sigurise teknike te konstatuara ne terren
nga personeli i kompanise. Ne baze te rregullores per sigurine ne pune, punonjesit qe shkelin
kete rregullore u jepet mase disiplinore (Verejtje) e cila do te mbahet ne zyren e punes . Nese
shkeljet do te vazhdojne msat disiplinore do te pershkallezohen deri ne pushimin e perhershem
nga kompania.

PPE, mos perdorimi i pajisjeve mbrojtese.

Punime ne lartesi pa masa sigurie.

Ngarja e makines me shpejtesi

Konsumim Alkoli ne orar pune.

Grindje ne vendin e punes.

Punime ne kushte te papershtatshme.

Mos zbatim i rregullores se HSE.

Komente.
 NEAR MISS REPORT
TIME & DATE: PLACE OF ACCIDENT :

SUPERVISOR: WITNESS SIGNITURE:

TIME & DATE:
 FORMULARI I INSPEKTIMEVE 3 MUJORE TE RRIPAVE PER PUNET NE
LARTESI

Data:

Perdoruesi:

Numri serik:

Nenshkrimi i Personit
Kompetent:

PERBERESIT GJENDJA PO JO

(nese po –
largoni prej
sherbimit)

Rripat Prerjet ose vjeterimet, gerryerja per shkak te

nxehtesise, tretesit ose drita ultra violete

Kopse e Kanxhave Shtremberimi, plasaritjet ne kanxhe (grep) ose ne

sigurese

Unazat-D Shtremberimi ose demtimet e tjera fizike

Shtrengueset dhe Shtremberimi ose demtimet e tjera fizike

Pershtateset
Qepja Fijet e thyera te prera ose te vjeteruara, demtim
per shkak te kontaktit me gerryeset e nxehta,
treteset, myku etj.

Litaret Prerjet, gerryerjet, demtimi per shkak te kontaktit

me nxehtesine, tretesit, gerryeset etj.
Shtremberimi dhe prishja per shkak te drites
ultraviolet.

____________________________________ _______________________________________

Personi Kompetent / Perdoruesi Supervizori Pergjegjes

____________________________________ _______________________________________
Data e Inspektimit Data e Inspektimit ne rradhe