Form E2 - Government Entity Quarterly Performance Report

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ADOSH -SF – Forms
Form E2 – Government Entity Quarterly Performance Report - Version 4.0 – 15th July 2024 Page 1 of 3
Form E2
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:
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 ADPHC
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 x1,000,000
Working Hours
KPI 2-05
Lost Time Injury Frequency Rate (LTIFR)
[Total Lost Time Injuries reported in KPI 2-02
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 E2 – Government Entity Quarterly Performance Report - Version 4.0 – 15th July 2024 Page 2 of 3
Form E2
(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 Cost 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 E2 – Government Entity Quarterly Performance Report - Version 4.0 – 15th July 2024 Page 3 of 3
Form E2
Number of OSH Employees
that passed the ADPHC-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 the quarter
and form F submitted (YES/NO)
If YES, include date of audit
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:
Name:
Signature:
Date: (DD/MM/YYYY) __/ __ / ____