Table of Contents

Daily
Request and Permit to Work FSEL 1
Request and Permit to Work Other4
Competent Person Nomination for PTW 1
Nomination for PTW Issuer 4
Workplace Safety Assessment 1
PTW and LOTO Log Sheet 4
Job Safety-Hazard Analysis 1
Approved PPE's T&P List 4
PPE's (Non-Returnable) Issuance Record Year 1
PPE's (Returnable) Issuance Record Year 4
PPE's Inspection Checklist 4
Issues To Be Considered While Selecting the PPE's 1
Scaffolding Inspection Checklist 4
Scaffolding Inspection Tag 1
Scaffolding Inspection Tag - Use with Harness 4

Weekly
Hazard Aspect Identification Risk Impact Assessment and Control Form
1
Isolation Certificate 4
Isolation Certificate (Process Trip System) 1
Hot Work Certificate 4
Mobile Crane Inspection Checklist 1
Noise Survey Results 4
First Aid Box Filling Requirement-Criteria 1
First Aid Box Items Medicines Consumption Record 4

Monthly
Solid Waste Disposal Site Inspection Form 1
Plant Evacuation Drill Checklist 4
Emergency Alarm Testing & Drill Record 1
Emergency Organization Chart 4

Quarterly
Emergency Organization Chart - Site Trip-Equip Breakdown 1
 Scaffolding Inspection Tag (Do Not Use) 4
List of Risk Assessments 1
PPE's Replacement Request Form 4

Annually
Pre-Employment Medical Assessment 1
Certificate of Fitness to Employee 4
Employees Health Assessment Form 1
Evaluation of Nominees for Safety Model Award 4
Nomination Form for Safety Model Award Safety Slogan Evaluation
Form 4
Safety Slogan Evaluation Form 4
1
2
 COMPETENT PERSON NOMINATION FOR PTW
Nomination Date: ________

S. No. Name Department Designation Remarks

Stamp

NOMINATION FOR PTW ISSUER

3
 Nomination Date: ___________
Sr. No. Name Department Designation Remarks

Stamp

4
Area/Activity: Assessment Date:

Assessed by: PTW #:

(Name & Sign)

S. Control
No Measure
. Hazards Description Status s Status
(if
require)

1. Electric Is this activity has risk of Electric

Shock/ Shock, electrocution, short
electrocutio circuiting?
n

2. Fire & Burn Is ‘Hot Work’ being carried out on or

adjacent to flammable
substance/gases, or gases under
pressure, or on pressurized vessels
or pipe work.

3. Slips, Trips Are there floor openings,

or Fall from wet/oily/uneven floors, trailing
height cables, conduits or pipes crossing
the floor, maintenance debris?

4. Other Is the work taking place adjacent

working to, above or below other working
parties parties?

5. Poor Is the work area tidy and free from

housekeepin rubbish and other waste before
g starting work?
of work area

6. Emergency Are fire exits, fire extinguishers, eye

access/egre wash bottles, emergency showers,
ss and emergency stop buttons,
equipment emergency access routes,
obstructed by the work process,
storage of material, plant or
vehicles?

7. PPE: Type Is the PPE of the correct type and

and grade standard required and any
specialized PPE to be used over and
above standard minimum
requirement (face shield, chemical
suit, dust mask, BA etc.) being used
correctly by appropriately trained

5
 personnel.

8. Falling Are there risks of objects falling into

objects the work area or risks of objects
falling from the work area?

9. Noise Is the work area noisy? Is a noise

assessment required?

10 Lighting Are the lighting levels adequate?

.

11 Environmen Have you considered all aspects

. tal and impacts to the environment for
the duration of the whole task
Hazards
process?

12 Isolation Is proper isolation provided as per

. mentioned on the permit?

13 Other risks Are there high levels of vibration,

. work repetitive, is the work area
exposed to the weather, is the work
in a remote area, alone work?

Note: Entries shall be made using a (NO HAZARDS) or X (HAZARD PRESENT)

If any column contains an X, adequate control measures must be implemented,
and the hazard reassessed before this must be rectified prior to work
commencement (contact SE or CP if required). A new assessment indicating no
general safety hazards exist must be performed after corrective action is taken
and work recommences. Details of control measures should be written and after
that status must be mentioned.

6
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.:00
HEALTH AND SAFETY FORM
FSEL-HS-F-009 PTW and LOTO LOG SHEET Page: 1 of 1

Issuance/
Competent Installation LOTO Installed By LOTO Cleared By
PTW No Detail CP Department Tag No Site Engr (Sign) Site Engr (Sign) Date Remarks
Person (CP) Date (Name) (Name)

Reviewed By:

7
 Job/Activity: Analyzed/revised date: Revision # JHA/JSA #

Job analyzed/revised by: JHA/JSA reviewed by:

Recommended Personal Protective Equipment:

Sr. Potential
Sequence of basic job steps Recommended Actions Responsible Person
No Hazards/Risks

General Hazards/Risk:

Abrasion Transport Projections

Burns Fire Radiation Light Temperature Others

Slipping Confined Space Incompatible

Cutting Corrosive Agents Drowning Biological Humid
Tools

Impact Falling Handling

Explosive Gases Asphyxiation Noise Ventilation PPE’s
High
Electricity Falling Object
Pressure Entanglement Inhale Toxic Agent Inhale Dust Vibration Tripping

Training Systems Equipment

Information Pressure Dirty Posture Spill

Approved by: __________________________________

(Manager)

8
 FOUNDATION SOLAR ENERGY LIMITED HEALTH AND SAFETY FORM
Rev. No.: 00

FSEL-HS-F-063 APROVED PERSONAL PROTECTIVE EQUIPMENTS (PPE'S)/TOOLS & SITE (T& P) LIST Page: 1 of 1

As of Date:

Description Approved Stock

Sr.No PPE'S/T&P Name Remarks
(Specification including Model No) Units Min Qty
Personal Protective Equipments (PPE'S)/Tools & Ste (T & P) List (General)

Personal Protective Equipment (PPE'S)/Tools & Plant (T & P) List (Special for Solar Site)

Note:

Prepared By: Approved By:

Name/Design. & Sign Name/Design. & Sign

Reviwed By:

Name/Design. & Sign

9
 PPE’s (Non-Returnable) ISSUANCE RECORD
S.No Designati Departme
Name Item item Item Date Sign Remarks
. on nt

Recorded By: ____________________ Reviewed By:

____________________

10
 PPE’s (Returnable) ISSUANCE RECORD YEAR

S. Departmen
Name Designation Item item Item Date Sign Remarks
No. t

Recorded By: ______________________

Reviewed By:____________________
11
12
 Date: _________________

Sr. PPE’s Ye N
Issues to be considered Remarks
No. Type s o

Is enough quantity available?

Is adequate for protection of eye and face?

1 Googles Is Maintained per manufacturer's
recommendations?

Is as per requirement?

Is enough quantity available?

Is adequate for protection of head?

2 Helmet Is Maintained per manufacturer's
recommendations?

Are helmets as per requirement?

Is enough quantity available?

Is adequate for protection of foot?

Safety
3 Is Maintained per manufacturer's
Shoes
recommendations?

Is as per requirement?

Is enough quantity available?

Is adequate for fall protection?

Safety
4 Is Maintained per manufacturer's
Harness
recommendations?

Is as per requirement?

Is Maintained per manufacturer's

recommendations?

Ear Is fit for use?

5 Plug/Mu Is as per requirement?
ff
Is Maintained per manufacturer's
recommendations?

6 Gloves Is enough quantity available?

Is adequate for protection of hand?

13
 Is Maintained per manufacturer's
recommendations?

Is as per requirement?

Is enough quantity available?

Is adequate for protection of hand from electrical

Electric hazard?
7 al
Gloves Is Maintained per manufacturer's
recommendations?

Is as per requirement?

Is enough quantity available?

Is adequate for protection?

8 Coverall Is Maintained per manufacturer's
recommendations?

Is as per requirement?

Is enough quantity available?

Is adequate for protection?

9 Fire Suit Is Maintained per manufacturer's
recommendations?

Is as per requirement?

Is enough quantity available?

Is adequate for protection during arc?

10 Arc Suit Is Maintained per manufacturer's
recommendations?

Is as per requirement?

Is enough quantity available?

Is adequate for protection of body?

Rain
11 Is Maintained per manufacturer's
Coat
recommendations?

Is as per requirement?

Is enough quantity available?

Is adequate for protection of hand during welding?

Welding
12 Is Maintained per manufacturer's
Gloves
recommendations?

Is as per requirement?

14
 Is enough quantity available?

Is adequate for protection of face during welding?

Welding
13 Is Maintained per manufacturer’s
Helmet
recommendations?

Is as per requirement?

Inspected By:
Reviewed By: ____________________
(Name & Sign)
(Name & Sign)
Sr.
PPE’s Type Issues to be considered Remarks
No.

Eye and Face Protection appropriate to the hazard present

Side Protectors used where flying objects hazards are
found
Eye protection incorporates prescription or can be worn
Eye and Face
1 without disturbing proper position of prescription lenses
Protection
Filter lenses with appropriate shade number available
where work involves injurious light radiation
Maintained per manufacturer’s recommendations
Eye and Face Protection appropriate to the hazard present
Hard hats used where there is the potential for head injury
from falling objects
Head Hard hats used where there is a potential for head injury
2
Protection from exposed electrical conductors
Bump cap use restricted
Maintained per manufacturer’s recommendations
Appropriate for protection from falling or rolling objects
Appropriate for protection from objects piercing the sole
Foot
3
Protection Appropriate for protection from exposed electrical
conductors
Maintained per manufacturer’s recommendations
Appropriate for protection from fall
Fall Appropriate for the task on hand
4
Protection
Fit for the user
Maintained per manufacturer’s recommendations
5 Hear Appropriate for protection from ear
Protection
Appropriate for the task on hand

15
 Fit for the user
Maintained per manufacturer’s recommendations
Hand Appropriate for protection from hazards present
6
Protection
Maintained per manufacturer’s recommendations
Hand Appropriate for protection from hazards present
Protection
7
from
Maintained per manufacturer’s recommendations
Electricity

Date: _____________ Considered By: ______________

SCAFFOLDING INSPECTION CHECK LIST

Scaffolding Serial # ----------------------- Location or Area:

--------------------------------------------

S.N
General Requirement YES NO Remarks
O
1 Is the scaffold being erected under the
direction of a competent person?

2 Is the footing sound and rigid - not set on soft

ground, frozen ground (that could melt), or
resting on blocks?

3 Is the scaffold able to hold four times its

maximum intended load?

4 Are guardrails and toe boards in place on all

open sides?

5 Is the platform complete front to back and

side to side (fully planked or decked, with no
gaps greater than 1 inch)?

6 Is the lumber free of cracks, splits, knots, or

damage?

7 Is the scaffold level?

8 Have all compounds been inspected for

defects such as broken welds, corroded
members, and missing locks, bent or dented
tubes?

9 Are all braces, bearer, and clamps secured all

16
 sections pinned or appropriately secured?

10 Is there a safe way to get on and off the

scaffold, such as a ladder (without climbing on
cross braces)?

11 Is the scaffold under125 feet in height?

12 Is the "X" bracing installed on the ends of the

scaffold and every third set of post
horizontally and every fourth vertical runner?

13 Where persons work under scaffold, is a 1/4

inch mesh screen provided between toe board
and guard rail or has the area below the
scaffold been cordoned off?

14 Is the scaffold over 6 feet high, (if yes) is

personal fall protection available, or are
guardrails in place?

15 Are guardrails 42 inches high?

16 Are toe boards in place and at least 4 inches

high?

17 Are mid rails or equivalent in place?

18 Does the scaffold have a height to base ratio

of at least 4:1?

19 Is the front of the scaffold within 14 inches of

the work?

20 Mudsills with a minimum dimension 10x10

inch

21 Base plate with a minimum dimension 5x5

inch.

Inspected By: ------------------------- Inspected Date:

-------------------------
(Name)
(Signature)

17
SCAFFOLDING INSPECTION TAG

SAFE FOR USE

INSPECTED DATE: ______________

INSPECTED BY: ________________

VALIDITY DATE: __________________

Back: Green

Front Back
18
SCAFFOLDING INSPECTION TAG

SAFE FOR USE

(With Harness)

INSPECTED DATE: ______________

INSPECTED BY: ________________

VALIDITY DATE: __________________

Back: White

19
 Area: Activity: Date: Rev. No.: Assessment No.:

People at Risk (including number): Employee Contractor Visitor Public

SECTION I: HAZARD/ASPECT IDENTIFICATION AND RISK/IMPACT ASSESSMENT

Risk/Impact=
Identified Hazard/Aspect Likelihood (L) Severity (S)
LxS
Sr. No.
Description Type Descriptor Rating Descriptor Rating

Guidelines for Risk/Impact Assessment

Measurement of Likelihood Measurement of Severity Risk/Impact Level

Description
Level Descriptor Description Level Equipment/
People Environment
Operation
Catastrophi Catastrophi Catastrophic
5 Almost 5
Frequent c c / Massive
Certain
Major
4 Likely Could easily happen 4 Major Major
Damage

3 Possible Could happen and has occurred here 3 Moderate Localized Moderate
or elsewhere Damage

20
 Minor
2 Unlikely Hasn’t happened yet but could 2 Minor Minor
Damage
5 10 15 20 25

4 8 12 16 20

3 6 9 12 15

2 4 6 8 10

1 2 3 4 5

SEVERITY

Slight L
1 Possible, but rare and only in extreme 1 Insignificant Insignificant
Rare Damage
circumstances I
K
E
L
I
H
O
O
D

SECTION II: RISK/IMPACT CONTROL

21
Haz. /Asp. Responsibility Planned Target Actual Reason(s), if
Recommended Control Measures
No. Date Completion Date Delayed Remarks
Name Signature

Carried out By: Name ________ Sign. _________, Name ________ Sign. ______ , Name ________ Sign. ________, Name ________ Sign. ________

Reviewed By: Name ________ Sign. _______

22
 FOUNDATION SOLAR ENERGY LIMITED
HEALTH AND SAFETY FORM Rev. No.:00

FSEL-HS-F-007 Isolation Certificate Page: 1 of 1

No. :

Initiated by: Closed By:

(Site Engineer) (Site Engineer)

23
 Verify By (Site Cleared By Verify By (Site
Lock & Tag Number Lock & Tag Location Lock & Tag Position Lock No. Date Initiator (CP) Checked By (CP) Date
Engr) (CP) Engr)

Initiated by: /Date: Closed By: /Date:

(Site Engineer) (Site Engineer)

24
25
27
 MOBILE CRANE INSPECTION CHECKLIST
Crane Model:
______________________________________________________________________

Maximum Crane Capacity:

___________________________________________________________

Maximum Boom Length:

____________________________________________________________

S.
NoItems Yes No Remarks
.
Is crane manufacturer’s manual
1
available at the work site?
2 Is crane load chart available?
Is the crane inspected by a third
3
party?
Are obvious crane modifications and
4 structural (welding) repairs certified
by a third party?
Is the crane operator certified by a
5
third party?
Are overhead power transmission
6
lines considered?
Is critical lift required? (Lifts over
7 power transmission lines or 90% of
the crane capacity)
Is boom angle indicator present and
8
functioning?
Is crane load cell or disengagement
9
device working?
Is crane hoist line inspected for
10 broken wires, crushing and correct
drum spooling?
Is fire extinguisher present in crane
11
cab?
12 Is crane horn functional?
Are crane controls clearly marked for
13
their functions?
Is load indicator of the crane
14
functional?
15 Are all the lights of crane functional?
16 Is crane leveled for operation?
17 Are outriggers in good condition?
Is crane staying on a fixed support? If
18 not, are requirements for floating
support met?

28
 19 Has the crane proper operator cabin?
20 Is the condition of tyres good?
Remarks:
_____________________________________________________________________________
___________________________________________________________________________________
__

Inspected By: ________________________ Inspection Date: _______________

(HSE Officer)
NOISE SURVEY RESULTS

Survey Date: Survey Time:

Site Load: MW Wind Speed:

Wind Direction:

Noise
Noise Level Noise
Point Level (dB) Noise
Area/Location (dB) Level (dB) Remarks
No. 1st Limit
2nd Reading Average
Reading
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

29
 FOUNDATION SOLAR ENERGY LIMITED
HEALTH AND SAFETY FORM
18
FSEL-HS-F-091 FIRST AID BOX FILLING CRITERIA
19
20
21

Sper Scientific (Model # 850014) Sound meter was used for measuring the noise.

Reviewed By: ____________________

FIRST AID BOX FILLING CRITERIA

Inspected Items & Quantity

Prepared By:
Reviewed By:
(Sr. HSE Officer)
(Medical Officer)

Date:
Date:
FIRST AID BOX ITEMS/MEDICINES CONSUMPTION RECORD

Location:________________
Period:_________________

30
 Date & Diagnosis/ User
S. No. Used Item Detail
Time Problem (Name & Designation)

Record By: ___________________ Reviewed By: ____________________

Reviewed Date: __________________
(HSE Officer/Doctor) Copy to Doctor/Clinic

31
 FOUNDATION SOLAR ENERGY LIMITE Rev. No.:
HEALTH AND SAFETY FORM 00

Solid Waste Disposal Site Inspection Page: 1 of

FSEL-HS-F-057 Form 1

WASTE DISPOSAL SITE INSPECTION

Date:
Sr. No Inspected Item Status Remarks

1 Contractor is disposing the waste as per contract.

2 During the transportation, waste is properly covered.

It is ensured that waste disposal is not degrading the

3
surrounding land.

4 It is ensured that waste disposal is not degrading the air.

It is ensured that waste disposal is not degrading the

5
ground/standing water.

6 Burning of plastic shopper and bag is not practiced.

During the collection of waste, Proper PPE, s are being

7
used.

It is ensured that waste disposal has not any bad impact on

8
community.

9 Disposal Area has not any obligation by Law/EPA.

Waste disposal site is away from community and colony

10
boundary.

Recyclable material (paper, plastic, plants leaves etc.) are

11
segregated and re-used/recycled.

Inspected By:
(Sr. HSE Officer)

33
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.: 00
HEALTH AND SAFETY FORM
Emergency Alarm Testing and Drill
FSEL-HS-F-017 Record

1.DRILL INFORMATION
Name of Building/Facility:

Location of Drill (Specific floor/wing/etc.):

Date of Drill:

Nearby Assembly Area(s):

Time Drill Initiated: Time All Occupants Vacated:

Elapsed Time:

Drill Monitor Name:

2.WEATHER
Temp: Cold / Warm / Hot/Moderate
Wind: Calm / Breezy / Windy
Precipitation: Sunny / Cloudy / Rain / Snow / Sleet

Ye N/
3. DRILL CHECKLIST: No Remarks
s A
A Pre-drill Assessment
1 Evacuation routes are posted.
2 Evacuation signs are in good condition.
3 Exits are clearly marked
4 Exit signs are properly illuminated.
5 Exit doors are operating properly.
6 Egress routes are free of obstruction
7 Egress routes are properly lighted.
B Communication
1 Drill is preannounced.
2 Fire Department is present for drill.

34
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.: 00
HEALTH AND SAFETY FORM
Emergency Alarm Testing and Drill
FSEL-HS-F-017 Record

3 Alarm monitoring company is notified.

4 Security is notified.
C Fire Containment
1 Doors and windows are closed.
2 Rooms are checked prior to closing doors.
3 Doors are left unlocked.
Fire extinguisher is taken to location of
4
fire.
5 Door hold-open devices are operating
properly.
D Evacuation
1 All occupants have participated and
evacuated.
2 Rest rooms were checked for occupants.
3 Evacuation is orderly.
4 Visitors are escorted and accounted for.
5 Special needs persons are
accommodated.
6 Elevators are used during evacuations.
7 Overall response of occupants is
satisfactory.
8 Noise level of evacuation is satisfactory.
E Utilities
1 Electrical appliances are turned off.
2 Lights are turned off.
3 HVAC units are shutdown.
F Plan
1 Evacuation is performed according to the
plan.
Occupants met at designated mustering
2
point according to the plan.
Designated meeting place(s) is located at
3
safe distances from Building
Fire drill/incident response team(s) has
4
responded according to plan.
Fire drill/incident response team(s) has
5
carried out assigned duties.
Fire department “mock” is notified
6
according to the plan.
G Fire Alarm Systems
1 Fire alarm is clearly heard in all areas.
2 Alarm monitoring company received
alarm.
3 Electro-magnetic locks are operating
appropriately.
4 Public address system is clearly heard in

35
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.: 00
HEALTH AND SAFETY FORM
Emergency Alarm Testing and Drill
FSEL-HS-F-017 Record

all areas.
5 Elevators are recalled to correct floor.

4. Number of Occupants Evacuated

Sr. No. Name Number Remarks

1 FSEL Employees
Contractor’s
2
Employees
3 Visitors
4 Total

5. METHOD OF DRILL ACTIVATION:

Alarm Activation: PA system/ In-House Word of Mouth/ Other
Any item receiving a “No” or “Unsatisfactory” is an item that the KPS should work on
to correct.
(See the areas of improvement)

6. COMMENTS/LESSONS LEARNT:

7. DOCUMENTATION:

Drill Lead by:

(Name)
(Sign)

Reviewed by:
(Name)
(Sign)

36
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.: 00
HEALTH AND SAFETY FORM
FSEL-HS-F-017 Plant Evacuation Drill Checklist

1. ALARM/SIREN TESTING:
Date:
Time:
Alarm Time Interval
Emergency Alarm (Fire) 10 sec on and 10 sec off and
continue for one minute
Note: Alarm was clearly heard in all areas of plant.
33

2. FIRE EMERGENCY DRILL:

Date:
Time:
PARTICIPANTS (PLANT EMERGENCY TEAM)

Sr. No Participant’s Name Designation Remarks

1
2
3
4

I. ACTIVITIES DONE:
 Fire drill was performed on system;
Outdoor Hydrant Indoor Hydrant Fire Extinguishers
Other
Location:

 Training or instructions were delivered on system;

Outdoor Hydrant Indoor Hydrant Fire Extinguishers

Other
Others Topic:
Delivered by:

II. ATTACHMENTS: Pictures Other Document

Arranged & Recorded By: Reviewed By:

37
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.: 00
HEALTH AND SAFETY FORM
FSEL-HS-F-017 Plant Evacuation Drill Checklist

Sr. HSE Officer

Manager/MR
Picture

38
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.: 00
HEALTH AND SAFETY FORM
FSEL-HS-F-018 Emergency Organization Chart Page: 1 of 1

EMERGENCY ORGANIZATIONAL CHART

1st Emergency Controller GM FSEL
Updated Date:

Will
help if 2nd Emergency Controller
require Will help/
support to
ETL

Emergency Team
Leader
On duty Site Engineer

Legends:

Plant Emergency Team First Aid Team Security Team Head Count
(Fire Fighting/Search & Rescue /Spill Control Team) (Mustering
On Duty Operation team
Each Point)
Will be called for help/support if require Departmental
Head/designated
person will count
the employees
Prepared By:_________________________
reaching at
Reviewed By:________________________ Approved By:_______________________
EMERGENCY RESPONSE PLANNING
(In case of Site Trip or Equipment Breakdown)

1st For Info/update Controller

Emergency GM

39 GM Solar
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.: 00
HEALTH AND SAFETY FORM
FSEL-HS-F-018 Emergency Organization Chart Page: 1 of 1

2nd Emergency Controller

SCAFFOLDING
Will help if require
INSPECTION TAG

DANGEROUS
Emergency Team
Leader
ON Duty Engineer

FOR USE
Must reach at Site Will help if require Must reach at
Site
INSPECTED DATE: ______________

INSPECTED BY: ________________ Note: All Maintenance Engineers & warehouse person must
reach at the plant in case of site trip/site equipment breakdown.

Prepared By:_________________________
VALIDITY DATE: __________________ Reviewed By:_________________________
Approved By:________________

40
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.: 00
HEALTH AND SAFETY FORM
FSEL-HS-F-018 Emergency Organization Chart Page: 1 of 1

Back: red

Front Back

41
42
 Part I: To be completed by the Candidate
PERSONAL DETAILS Date of Examination:

NAME : BLOOD GROUP:

ADDRESS: MARITAL STATUS :

DATE OF BIRTH: PROPOSED Position:

NATIONALITY: GENDER:
SOCIAL / OCCUPATIONAL HISTORY
1. Do you smoke? If so how many per day
2. Have you been exposed to any known occupational hazard such
as noise, radiation, dust, chemicals, gas & lead etc.?
3. Have you used protective clothing, safety glasses or hearing
protection?
4. Have you ever developed any medical condition in connection
with your occupation? If so please give details e.g. Hearing
loss/skin condition /wheeze/backache/muscle strain/blood
disease etc?
5. Have you suffered any industrial injury?
If so please give details.
6. Have you had any previous audiometric screening?
Was this normal? State when and where?
7. Have you had previous lung function screening?
Was this normal?
State when and where?
8. Do you have any disabilities?
Use a separate sheet if required

9. Do you have any Surgery history? if yes than which

10. Have you ever been rejected from employment or insurance on

medical grounds?
11. Have you received compensation for an industrial claim /or is
there any industrial claim pending?
12. Do you have false tooth/teeth?
13. Do you have histroy of Epilepsy or any Neurological disorder?
14. Have you been hospitalized in the last five years? If yes please
provide details?'
15. Emergency Contact No of relative/family

CONFIDENTIAL – WHEN COMPLETED

Employee Name:

43
MEDICAL HISTORY REQUIRING SPECIAL CONSIDERATION
DO YOU HAVE OR HAVE BEEN DIAGNOSED AS SUFFERING FROM ANY OF THE FOLLOWING:
Please include any family history of the following in addition Please Elaborate
1. Chest pain / heart disease Yes No

Yes No
2. High blood pressure /Low Blood Pressure

3. Asthma / Epilepsy / diabetes Yes No

4. Peptic ulcer disease Yes No

5. Kidney disease (eg. Stones ) Yes No

6. Psychiatric disorder eg. anxiety, Yes No
Depression
7. Tuberculosis Yes No

8. Cancer/HIV Yes No
9. Have you or anyone in your family an Yes No
existing medical condition?
10. Vaccination history: Poliomyelitis BCG/ DPT /Tetanus Hep.B Measeles

Meningitis

Approx. Date:

DECLARATION
PLEASE READ THE FOLLOWING STATEMENT AND IF YOU AGREE, SIGN AND DATE.

“I DECLARE THE ABOVE TO BE TRUE TO THE BEST OF MY KNOWLEDGE. I AGREE THAT THE RESULTS
OF THIS MEDICAL EXAMINATION, INCLUDING APPROPRIATE INVESTIGATION CARRIED OUT IN
ORDER TO ESTABLISH MY MEDICAL FITNESS WILL BE REVEALED TO THE COMPANY MEDICAL
OFFICER.
I ACCEPT THAT FSEL WILL NOT BE LIABLE FOR ANY PRE-EXISTING MEDICAL
CONDITION IN MYSELF OR MY DEPENDENTS UNLESS EXPRESSELY STATED IN
WRITING WITHIN THE COMPANY POLICY.
SIGNATURE OF EXAMINEE: ___________________

DATE: _____________________________________

Part II – To be filled out by examining physician at question & answer base:

DO YOU HAVE OR HAVE YOU HAD ANY SIGNIFICANT OR RECURRENT PROBLEMS WITH THE FOLLOWING?
Please Elaborate

44
1. Backache / joint or muscular pain Yes No

2. Hernia / rupture Yes No

3. Visual impairment Yes No
4. Perforated eardrum / discharge from ear Yes No
5. Recurrent indigestion Yes No
6. Liver/ gall bladder disease Yes No
7. Changes in bowel habit / diarrhea Yes No
8. Blood in stool / piles, hemorrhoids Yes No
9. Shortness of breath /coughing up blood Yes No
10. Recurrent bronchitis / pneumonia Yes No
11. Blood in urine / kidney complications Yes No
12. Headaches / migraine / dizziness Yes No
13. Skin trouble (e.g. dermatitis / eczema, etc) Yes No
14. Surgical operations Yes No

15. Hospitalization Yes No

16. Fear of flying / fear of heights Yes No

17. Tropical disease / venereal disease Yes No

18. History of alcohol / drug abuse Yes No

19. Do you have any allergies? Please list. Yes No

20. Do you have any current illnesses? Please Yes No
list.
21. Are you receiving any medication at Yes No
present? Please list.
22. Have you attended a dentist in the last year? Yes No

23. Are you undergoing dental treatment? Yes No

24. Date of last tetanus booster. Yes No

EXAMINING PHYSICIAN’S COMMENTS EXAMINEE SIGNATURE

CONFIDENTIAL – WHEN COMPLETED

45
TO BE COMPLETED BY EXAMINING DOCTOR
PREDICATED CHEST
CHEST FULL
HEIGHT WEIGHT Age BP PULSE RESP: RATE FORCED
INSPIRATION
EXPIRATION
PFR

VISION SCREENING -DISTANCE VISION SCREENING - NEAR COLOUR VISION

L L NORMAL
R R ABNORMAL

1. EYES/PUPILS
2. EAR, NOSE & THROAT
3. TEETH & MOUTH
4. LUNGS / CHEST
5. CARDIOVASCULAR
6. ABDOMEN
7. MUSCULOSKELTAL
8. SKIN
09. IDENTIFYING MARKS
(E.G. TATTOOS/SCARS ETC.)
INVESTIGATIONS RESULTS Remarks
LFT
Blood Sugar
HBs Ag. ANTI. HCV
CBC
Urine D.R
CHEST X-RAY
OTHER

I CERTIFY THAT

DATE OF MEDICAL

SIGNED:__________________________EXAMINING PHYSICIAN

CLEARED FIT FOR EMPLOYMENT ON NOT FIT FOR EMPLOYMENT ON

MEDICAL GROUNDS. MEDICAL GROUNDS
__________________________
Dr._____________________
Medical Officer Date :

CONFIDENTIAL – WHEN COMPLETED

46
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.: 00
HEALTH AND SAFETY FORM
FSEL-HS-F-031 Certificate of Fitness to Employee Page: 1 of 1

CERTIFICATE OF FITNESS TO EMPLOYEE

Name: _____________________ Department:______________________

Employee No. _______________ Date:_______________
1. The above named employee is considered:
Fit for unrestricted employment
Fit with the following recommendations and/or restrictions

Fit for proposed job role. Please refer to Doctor/Manager if any proposed job
change
Not fit for employment

2. Additional Information:
Number of declared days absence from work due to ill health in last
Days
2 years
Number of declared incidences of absence from work due to ill health in Incidenc
the last 2 years es
Estimated risk of repeated or prolonged absence from work Low
Medium
High
3. Doctor Signature & Stamp:

Sign:

Stamp:

47
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.:
HEALTH AND SAFETY FORM 00

EVALUATION OF NOMINEES FOR SAFETY MODEL Page: 48

FSEL-HS-F-060 of 1
AWARD

Sr. Score Obtained

Detail
No.
1 How many safety violations did record against the nominee
during the period?
No: 10 Less than 3: 7 Less than8:3 More
than 8: 0
2 How many safety talks did he attend or participate during
the period?
More than 20: 10 More than 10: 7 Less than 10:3
No: 0
3 How many safety trainings did he attend or participate
during the period?
More than 5: 10 More than 3: 7 Less than 3:3
No: 0
4 How many safety talks did he deliver during the period?
More than 10: 10 More than 5: 7 Less than 5:3
No: 0
5 How much has he knowledge regarding the safety?
Excellent: 10 Good: 7 Satisfactory: 3 poor: 0
6 How many near miss / hazards did he report during the
period?
More than 10: 10 More than 5: 7 Less than 5:3
No: 0
7 How much strictly did he follow the safety procedure?
Excellent: 10 Good: 7 Satisfactory: 3 poor: 0
8 How his behavior did remain for compliance of safety and
SOP during the period?
Excellent: 10 Good: 7 Satisfactory: 3 poor: 0
9 Did he directly expose to work and risks/hazards?

48
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.:
HEALTH AND SAFETY FORM 00

EVALUATION OF NOMINEES FOR SAFETY MODEL Page: 49

FSEL-HS-F-060 of 1
AWARD

Yes: 10 Middle: 5 No: 0

10 Did he perform special or extra ordinary activity i.e.,
prevention of accident at plant, other safety improvement
etc. for promotion of safety at the plant and what was
effects of this activity/improvement?
Yes: 10 Middle: 5 No: 0
Total (100)
Year: Date:

Evaluated by:
Evaluation Reviewed By:
(Name & Sign)
(Name & Sign)

49
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.:
HEALTH AND SAFETY FORM 00
Nomination Form For Safety Page: 1 of
FSEL-HS-F-059 Model Award 1

NOMINATION FOR SAFETY MODEL AWARD (Month

Year)

Name: Designation:

Department:

DETAIL: (Why are you recommending this person for

safety award?

Recommended By:

Engineer/Officer

Approved By:

50
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.:
HEALTH AND SAFETY FORM 00
Nomination Form For Safety Page: 1 of
FSEL-HS-F-059 Model Award
FOUNDATION SOLAR ENERGY LIMITED
1
Rev. No.:00
HEALTH AND SAFETY FORM

FSEL-HS-F-061 SAFETY SLOGAN'S EVALUATION FORM Page: 1 of 1

Evaluation Date:

MARKS OBTAINED
Participant's Name REMARKS
Appearance Understanding Language Innovation If special TOTAL

(Manager)
Marking Criteria
Excellent (20) Good (15) Ordinary/Average (10) Below average (0)

Evaluation done by: Evaluation Reviewed by:

(Name ) (Name )

(Sign )

(Sign)

51
 FOUNDATION SOLAR ENERGY LIMITED Rev. No.:
HEALTH AND SAFETY FORM 00
Nomination Form For Safety Page: 1 of
FSEL-HS-F-059 Model Award 1

52