Form E - Entity Quarterly OSH Performance Report

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ADOSH-SF – Forms
Form E – Entity Quarterly OSH Performance Report - Version 4.0 – 15th July 2024 Page 1 of 4
Form E
General Information
Classification Code: Registration
Number:
Name of Entity: OSHMS Approval
Date:
Address of Entity: Telephone Number
Contact Details of
Authorized Person:
Name:
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:
YYYY
☐ Q1 (Jan-Mar) ☐ Q2 (Apr-Jun) ☐ Q3 (Jul-Sep) ☐ Q4 (Oct-Dec)
Reporting
Timeframe: Mid April Mid July Mid October Mid-January
Occupational Health & Safety Performance – Mandatory Reporting to Sector Regulatory Authority
Note: Refer to ADOSH-SF - Mechanism 11.0 for reporting of incident with multiple consequences and its schedule B and C
for Guidance on Injuries & Illness
Occupational Health & Safety Performance Summary for Entity, Contractors & Other Persons
KPI 2-01 Total Incidents (From My Entity and Non- Nominated Contractor)(sum of KPI 2-02 & 3-
01)
Occupational Health & Safety Performance Summary for Entity
KPI 2-02 Total Incidents (From my Entity)
(Total No. of incidents that occurred during the reporting quarter)
Entity (s) Employees Injuries & Illness
Consequences No. Lost
Workdays Other Consequences No.
Lost Time Injuries
Fatality Serious Dangerous
Occurrence
Permanent Total Disability Equipment / Property
Damage
Permanent Partial Disability
Lost Workdays Cases
a) Lost Workdays Injuries
b) Lost Workdays
Occupational Illness
Restricted Workday Case
Medical Treatment Case
Total Consequences (Summation of Injuries, illnesses and other Consequences)
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)]
Number of Total Injuries
& Illness Reported in
the Reporting Period
Number of
Working Hours
in Reporting
Period
TRC x 1,000,000
Working Hours
KPI 2-04
Lost Time Injury Severity Rate (LTISR)
[Total Lost Workdays reported in KPI 2-02]
Zero LWDs for Fatality & Permanent Total
Disability
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 Working Hours
KPI 2-05
Lost Time Injury Frequency Rate (LTIFR)
Number of Lost Time
Injuries in the Reporting
Period
Number of
Working Hours
in Reporting
Period
No. of LTI’s x 1,000,000
Working Hours

ADOSH-SF – Forms
Form E – Entity Quarterly OSH Performance Report - Version 4.0 – 15th July 2024 Page 2 of 4
Form E
[Total Lost Time Injuries reported in KPI 2-02
(Fatality, Permanent Total Disability,
Permanent Partial Disability & Lost Workdays
Cases)]
KPI 2-06
Number of Near Miss & First Aid Cases for
Entity:
Near Miss First Aid Cases
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
Total Incidents (From Non-Nominated
Contractor)
(total No. of incidents that occurred during the reporting
quarter)
Contractor (s) Employees Injuries & Illness Consequences No. Other Consequences No.
Lost Time Injuries
Fatality Serious Dangerous Occurrence
Permanent Total Disability Equipment / Property Damage
Permanent Partial
Disability
Lost Workdays Cases
a) Lost Workdays
Injuries
b) Lost Workdays
Occupational Illness
Restricted Workday Case
Medical Treatment Case
Total Consequences (Summation of Injuries, illnesses and other Consequences)
KPI 3-02
Number of Near Miss & First Aid Cases for
Contractors:
Near Miss First Aid Cases
KPI 3-03
Number of
Monitoring
Activities
Performed on
Contractor(s) /
Supply Chain by
Entity
(nominated/ non-
nominated):
Total No. of Contractors Inspections Performed on Contractors
Review / Approval of Contractor OSH
Procedures.
Contractor Incidents Investigated by
Entity.
Specific Requirement / Part System Audit
Performed on Contractors Corrective Notices Issued to Contractors:
Full OSHMS Audit Performed on Contractor Breach Notices Issued to Contractors:
Consequences Summary for Other Persons (Visitors, Students, Hotel Guests, Passengers,
etc.)
KPI 4-01
Number of Fatalities & Injuries for other Persons:
Total consequences (Summation of Fatalities &
Injuries)
Fatality Other Injuries
KPI 4-02
Number of Near-Miss & First Aid Cases for other
Persons:
Near Miss First Aid Cases
OSH Resources, OSHMS Development, Implementation and Enforcement Summary for Entity
KPI 5-01- OSH
Resources
(Cumulative)
Number of OSH
Employees
Number of OSH
Nationals Employees
No. of OSH Nationals Employees x
100
Number of OSH Employees

ADOSH-SF – Forms
Form E – Entity Quarterly OSH Performance Report - Version 4.0 – 15th July 2024 Page 3 of 4
Form E
Number of OSH
Employees that passed the
ADOSH-SF Practitioner
Course
Number of OSH Employees Registered at Qudorat till date
KPI 5-02
Average Number of
Training Hours per
Employee
Number of OSH
Training Hours
Undertaken
No. of OSH Training Hours undertaken by Employees
Total No. of Employees
No. of Participants Title Training Level Training Provider Training Hours
Note: Additional information can be attached on a separate sheet if required
KPI 5-03
Third Party OSHMS Compliance
Audit
Annual 3rd Party OSHMS Compliance Audit conducted during this
quarter and form F submitted (YES/NO)
If YES, include date of audit
KPI 5-04
Number of Corrective Notices (warning
notices, improvement notices) received from
the SRA as a result of non-compliance to
OSHMS requirements
Number of warning notices received:
Number of improvement notices received:
Number of prohibition notices received:
KPI 5-05
Number of Breach Notices (fines / penalties /
enforceable undertakings) received from the
SRA as a result of non-compliance to OSHMS
requirements
Number of fines / penalties received:
Number of enforceable undertakings (entity’s
commitment to spend money to rectify OSHMS non-
compliance):
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):
Official
Stamp:
Date :
(DD/MM/YYYY) _____ / _____ / _____
Official Use
Remarks :
Relevant Authority Stamp Entered into Database by:
Name:
Signature:
Date: (DD/MM/YYYY) _____ / _____ / _____
Reviewed by:

ADOSH-SF – Forms
Form E – Entity Quarterly OSH Performance Report - Version 4.0 – 15th July 2024 Page 4 of 4
Form E
Name:
Signature:
Date: (DD/MM/YYYY) _____ / _____ / _____