Form A - Registration for Development of an OSHSM

Article-level navigation isn't available for this document — showing the full text as extracted.

ADOSH-SF – Forms
Form A – Registration for Development of an OSHSM - Version 4.0 – 15th July 2024 Page 1 of 2
Form A
General Information
Name of Entity:
Type of Business Activities:
Sector Name:
 Building and Construction  Education
 Food  Commercial
 Industry  Tourism & Culture
 Waste  Transport
 Health  Energy
Number of Employees:
Current OSH Resources: Director / Manager: Advisor / Officer /
Technical / Other:
Contact of Head Office within
Emirate:
Address:
Coordinates:
Zone : _______________
Northing : _______________
Easting : _______________
Telephone No.: E-mail Address:
Fax No.: P.O. Box:
Authorized Contact Person:
Authorized Contact Person
Position / Title:
Contact Details of Authorized
Person:
Telephone No.: E-mail Address:
Fax No. : P.O. Box :
Other Offices / Sites / Projects
Operating Under this Entity
Operating License:
Address: Coordinates:
Zone Northing Easting
Location Map(s):  Location map(s) of Head Office and Branches attached.
Schedule of Developing & Implementing of OSHMS
Target Date for Completing the
Development of OSHMS: ___ ___ (Day) ___ ___ (Month) ___ ___ ___ ___ (Year)
Occupational Health & Safety Management System (OHSMS)
 Have an OHSMS in place and certified to OHSAS 18001.
 Have an OHSMS in place based on OHSAS 18001 but not certified by third party.
 Have an OHSMS in place but not certified by third party.
 No OHSMS in place.

ADOSH-SF – Forms
Form A – Registration for Development of an OSHSM - Version 4.0 – 15th July 2024 Page 2 of 2
Form A
Declaration
I declare that all information provided in this document is true, correct and complete.
I understand that if I utilize the service of consultants for OSH MS development and/or implementation that they must be
registered to perform this work in the appropriate category as per ADPHC’s requirements.
Signature of the
Authorised
Contact Person:
Official
Stamp :
Date :
(DD/MM/YYYY)
Official Use
Assigned Classification Code: _____________________________________________________________
Assigned Registration Number: ____________________________________________________________
Deadline for completing the development of OSHMS: ___ ___ (Day) ___ ___ (Month) ___ ___ ___ ___ (Year)
Note: Implementation of the Entity’s OSHMS shall commence within 30 days of receiving approval from the concerned SRA.
Note: Incident Reporting Requirements shall commence from the date of nomination / notification.
Note: OSH Performance Reporting Requirements shall commence in the quarter following quarter of approval.
Note: Annual Third Party External Compliance Audit shall be undertaken with (12) twelve months from the date of approval.
Relevant Authority Stamp Entered into Database by:
Name:
Signature:
Date: (DD/MM/YYYY) _____ / _____ / _____
Reviewed by:
Name:
Signature:
Date: (DD/MM/YYYY) _____ / _____ / _____