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FORM E
ENTITY QUARTERLY EHSMS PERFORMANCE REPORTING

General Information

Classification Code: Registration Number:

Name of Entity:

Address of Entity: Telephone Number:

Working Hours Performed


Number of Employees:
this Quarter:

Reporting Period: Q1 (Jan-Mar) Q2 (Apr-Jun) Q3 (Jul-Sep) Q4 (Oct-Dec)


Year: ___
End of the second End of the second End of the second End of the second
Reporting Timeframe: week in April week in July week in October week in January

Environment, Health and Safety Incident and Consequence Summary


(EM = Employee of the Entity OP = Other Persons)

KPI 2-01 Total Number of EHS Incidents Reported: EM: OP: Total:

EM: OP: EM: OP: EM: OP:

Restricted Reportable
Near Miss:
Health and Safety Workday Case: Occupational
Summary: Illness /
First Aid Injury: Lost Time Injury: Disease:
(Consequences of Reportable
reported H&S Equipment /
Dangerous
incidents) Property Damage:
Occurrence:
Fatality:
Medical Reportable
Treatment Case: Serious Injury:

Environment Environment Environment


Minor: Moderate: Major:

Spill / Release / Discharge to Land:

Environment Spill / Release / Discharge to Water, including Groundwater:


Summary:
Release / Discharge to Atmosphere:
(Consequences of Environmental Noise / Vibration:
reported
Environment Unauthorized / Accidental Vegetation Removal or Harm:
incidents)
Harm to Animal Species:

Unauthorized / Accidental Damage to Heritage Site / Item:

Other (Provide Details):

Environment, Health and Safety Performance - Compulsory Reporting to Relevant Authority


Note: Refer to the AD EHSMS Glossary of Terms for definitions of EHS terms.
Number of
KPI 2-02 Number of UAE Nationals in No. of Nationals x 100
Employees in EHS
EHS Department No. of Employees in EHS Dept.
Department
EHS Department
Resources

Number of EHS
KPI 2-03 No. of EHS Training Hours undertaken by Employees
Training Hours
No. of Employees
Undertaken
Average Number of
Training Hours per
Employee

AD EHSMS RF - Version 2.0 February 2012 Page 1 of 3


FORM E
ENTITY QUARTERLY EHSMS PERFORMANCE REPORTING

Number of Lost Time Number of Working


No. of LTIs x 1,000,000
KPI 2-04 Injuries in the Reporting Hours in Reporting
Period Period Working Hours
Lost Time Injury Frequency Rate (LTIFR)

Number of Work Days Number of Working


No. of Days Lost x 1,000,000
KPI 2-05 lost due to Injuries in Hours in Reporting
the Reporting Period Period Working Hours
Lost Time Injury Severity Rate (LTISR)

Number of Total Number of Working


KPI 2-06 TRC x 1,000,000
Reportable Cases in Hours in Reporting
the Reporting Period Period Working Hours
Total Reportable Case Frequency (TRCF)

Percentage Reduction
KPI 2-07 or Increase
This Reporting Quarter Previous Reporting Quarter
(Indicate reduction as a
Power Consumption negative figure eg 3.5 %)
kW h Per
Total kW h kW h Per Employee Total kW h kW h Per Employee
(Total Kilowatts Hours (kW h) and Employee
kW h per Employee)

KPI 2-08 Percentage Reduction


or Increase
Water Consumption This Reporting Quarter Previous Reporting Quarter
(Indicate reduction as a
negative figure eg 3.5 %)
Water use (in production
processes, office activities or as
Total m3 m3 Per Employee Total m3 m3 Per Employee m3 Per Employee
drinking water)
(Total cubic meters (m3) and m3
per Employee)
Percentage Reduction
or Increase
KPI 2-09 This Reporting Quarter Previous Reporting Quarter
(Indicate reduction as a
Paper Consumption negative figure eg 3.5 %)
Average No. of Pages used per Average No. of Pages used per % Per Employee Increase
Average number of paper pages Employee Employee or Decrease
used per employee per month

Percentage Reduction
KPI 2-10 or Increase
This Reporting Quarter Previous Reporting Quarter
(Indicate reduction as a
Fuel Consumption negative figure eg 3.5 %)
Average fuel Number of Average fuel
Average fuel consumption of entity Number of vehicles consumption of vehicles owned consumption of
owned and /or operated vehicles. % Fleet Fuel Consumption
owned and/or vehicles and/or vehicles
operated by entity (Combined Cycle operated by (Combined Cycle Increase or Decrease
(Liters per 100 kilometers) L/100 klms) entity L/100 klms)

Percentage Reduction
KPI 2-11 or Increase
This Reporting Quarter Previous Reporting Quarter
Non-Hazardous Waste Disposal (Indicate reduction as a
negative figure eg 3.5 %)
Amount of non-hazardous (solid Solid (kg) Liquid (L) Solid (kg) Liquid (L) Solid Liquid
and liquid) waste collected by
Service Providers for disposal.

KPI 2-12 Percentage Reduction


or Increase
Non-Hazardous Waste Recycling This Reporting Quarter Previous Reporting Quarter
(Indicate reduction as a
Amount of segregated non- negative figure eg 3.5 %)
hazardous (solid and liquid) waste Solid (kg) Liquid (L) Solid (kg) Liquid (L) Solid Liquid
collected by Service Providers for
recycling / reuse / further
processing.
KPI 2-13 Percentage Reduction
This Reporting Quarter Previous Reporting Quarter or Increase
Hazardous Waste Disposal (Indicate reduction as a
negative figure eg 3.5 %)
Amount of hazardous (solid and Solid (kg) Liquid (L) Solid (kg) Liquid (L) Solid Liquid
liquid) waste collected by Service
Providers for disposal.
AD EHSMS RF - Version 2.0 February 2012 Page 2 of 3
FORM E
ENTITY QUARTERLY EHSMS PERFORMANCE REPORTING

KPI 2-14 Percentage Reduction


This Reporting Quarter Previous Reporting Quarter or Increase
Hazardous Waste Recycling (Indicate reduction as a
negative figure eg 3.5 %)
Amount of hazardous (solid and
Solid (kg) Liquid (L) Solid (kg) Liquid (L) Solid Liquid
liquid) waste collected by Service
Providers for recycling / reuse /
further processing.

KPI 2-15 Number of warning notices received:

Number of improvement notices received:


Number of written warning notices received from the
SRA as a result of non-compliance to EHSMS
requirements Number of prohibition notices received:

KPI 2-16 Number of penalties / fines received:

Number of enforceable undertakings:


Number of fines / penalties / prosecutions received
from the SRA as a result of non-compliance to
Total value of all fines / penalties/ enforceable
EHSMS requirements
undertakings enforced (AED):

Contractor / Supply Chain Monitoring Activities

KPI 2-17 Review / Approval of EHS Procedures: Specific Requirement / Part System Audit:

Inspections Performed on Contractors: Full EHSMS Audit Performed:


Number of
Monitoring Corrective Actions Issued by Entity to
Activities of Incidents Reported by Contractors:
Contractors:
Contractors /
Supply Chain: Contractor Incidents Investigated by Entity: Breach Notices Issued to Contractors:

Declaration
I declare that all information provided in this document is true, correct and complete.

Signature of the
Official
Authorised
Stamp:
Contact Person :

Date : _____ / _____ / _____

Official Use
Remarks :

Relevant Authority Stamp Entered into Database by:


Name:

Signature:

Date: _____ / _____ / _____

Reviewed by:
Name:

Signature:

Date: _____ / _____ / _____

AD EHSMS RF - Version 2.0 February 2012 Page 3 of 3