Form E5 - OSH Implementation Costs in Government Entities

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ADOSH-SF – Forms
Form E5 – OSH Implementation Costs in Gov. Entities - Version 4.0 – 15th July 2024 Page 1 of 2
Form E5
General Information
Name of Entity: Classification
Code:
Type of Business Activities:
Address:
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 :
Annual Budget allocated for OSHMS
implementation (AED): Year:
Details of Actual Expenditure (during the same year)
1. OSH Management Costs (AED)
Manpower:
OSH Manpower Direct Costs
(Salaries of full time OSH staff, Part time
OSH staff, internal OSH consultant and
related financial costs)
OSH Manpower Indirect Costs
(Man hours lost for non-OSH staff who have
spent time managing OSH issues, through
supervision, inspection, internal audit, etc)
Training:
OSH Training Direct Costs
(Internal and external OSH training)
OSH Training Indirect Costs
(Man hours lost during internal and external
training)
Events/Campaigns:
OSH Awareness Events/Campaigns
Direct Costs
(Costs of OSH special events/campaigns)
OSH Awareness Events/Campaigns Indirect
Costs
(Man hours lost during OSH special
events/campaigns)
Consultancy/Audits:
OSH Consultancy Costs
(Cost of consultancy services for gap
analysis, risk assessment, system
development, etc)
Third Party Audit
(Cost of third party annual audits)
Equipment:
OSH Equipment Capital Costs
(Purchase of OSH equipment, such as fire
extinguishers, first aid kits, etc. and cost of
safety system purchases or upgrades such
as alarm systems)
OSH Equipment Maintenance Costs
(Maintenance of OSH equipment)
Other Costs related to/associated with OSH Management:

ADOSH-SF – Forms
Form E5 – OSH Implementation Costs in Gov. Entities - Version 4.0 – 15th July 2024 Page 2 of 2
Form E5
2. OSH Incidents Costs (AED)
Assets:
Repair & Maintenance Costs
(Property, Machinery, Structure, Vehicle,
etc.)
Replacement Costs
(Property, Machinery, Structure, Material,
Vehicle, etc)
Restoration/Productivity:
OSH Incident Scene / Area Restoration
Costs
(Cost of cleanups, arrangement to make the
area safe)
Productivity Loss
(Based on monthly average wage per Grade,
total work hours lost per month and total work
hours per month)
Legal:
Legal Cost
(lawyers, Judicial prosecutions, etc) Compensation Claims
Injury:
Injury Cost
(Treatment, Hospital, Transport, Insurance,
etc.)
Other Costs
(relevant to / associated with the Incident)
Total Expenditure for OSH
Implementation:
OSH Management
Costs (AED)
OSH Incidents Costs
(AED)
Grand Total
(AED)
Comments (Please add any additional comment if needed)
Declaration
I declare that all information provided in this document is true, correct and complete.
Signature of the
Authorized Contact
Person:
Official
Stamp :
Date :
(DD/MM/YYYY) _____/_____/_____