ALKIFAH HOLDING COMPANY

ALKIFAH CONTRACTING COMPANY (KCC) NEAR MISS/POTENTIAL HAZARD FORM

1. 2. 3. This Form must be completed with corrective actions and direct Managers comments before returning to Safety Dept. rovide the filled form immediately to Safety Department within 2! hours by" #mail" soman.dinesh@alkifah.com; & $ontact" 038-45-3673 Project Safet !ana"er#Safet $ffice %ill retain this ori"inal form and %ill send a co& to Safet 'e&artment. ()ead $ffice* <Customer Logo>

+n the case of Serious %arm or &ossi,le Serious %arm- &lease contact .rea#Project Safet $fficial at //////////////// &ear Miss" . &otential ha0ard or an 1n&lanned e2ent that did not res1lt in an inj1r - illness- e3&os1re or dama"e- ,1t had the &otential to do so. 4here %as 5$ sli&- tri&- fall- &1nch- ,r1ise- strain- fire or e3&os1re.

1.

erson's( )nvolved6 7m&lo ee 8

5ame6 9ontractor $ther(S&ecif *6 //////// 'e&artment#Section6

:.

Details of near miss. ;ocation6 'ate6 4ime6 am # &m

3.

Severity6 <atal Serio1s )arm <irst .id 'octor !inor )arm )os&ital 5o )arm # 5ear !iss $ther

4.

Treatment6 5il

=hat treatment %as "i2en > ? =hom 5. Description of what happened6

6.

Describe the cause of the near miss.

9ontri,1tor <actors (refer to these %hen identif in" the ca1se of the near miss. )mmediate $auses - @1ardin" - 'efecti2e tools or eA1i&ment - )a0ardo1s arran"ements - Bnsafe conditions - Bnsafe desi"n - )o1sekee&in" - 7n2ironmental conditions Substandard *cts - $&eratin" %itho1t a1thorit - 'isa,lin" safet de2ices - Bsin" 1nsafe eA1i&ment - 5on 1se of Personal Protecti2e 7A1i&ment - 5on 1se of lock o1t # isolation s stems - Bnsafe &ositionin" - 'istraction # foolin" a,o1t

lease complete the other side of this form

7.

%as a significant ha+ard been identified ,

C#5

ALKIFAH HOLDING COMPANY

ALKIFAH CONTRACTING COMPANY (KCC) NEAR MISS/POTENTIAL HAZARD FORM
+f es- &lease in2esti"ate this ha0ard and 1&date the )a0ard De"ister in o1r de&artment or section accordin"l 8. F. $hance of the near miss recurring6 $ne off 'ail =eekl !onthl 6 !onthl E
<Customer Logo>

$orrective *ction6 (=hat %ill ,e done to minimise the risk of this happening a"ain* *ction -y .hom $ompleted

Person in control of the %ork&lace6 Si"ned6 G0. Managers $omments6

5ame6 Position6

Si"ned6 'ate6 GG. %ealth and Safety $o/ordinators comments6

Position6

+s &ost critical e2ent testin" reA1ired +f es- ad2ise $cc1&ational )ealth 51rse

C#5 C#5 'ate6

12.

&ear Miss 0egister and all corrective actions completed 6

Si"ned6

'ate6

Project Safet !ana"er#Safet $ffice %ill retain this ori"inal form and %ill send a co& to Safet 'e&artment