Document No: OHSMP 13 -F
Issue Date: 13/02/2014
“Safety Man of the Month” Evaluation Form Revision: 0
Page 1 of 1
Project No: Date: For the month of:
Project Name:
Nominee: Name: Number:
Item Category Score Comments
Not involved in any accident/ incident for at least
1. /10
Six months
Not warned due to safety violations for at least
2. /10
Six months
3. Correct use of PPE /10
Observing/Obeying site HSE Rules, Safety
4. /10
Signs & Instructions.
5. Following the Superior’s instructions /10
6. Contributing towards good housekeeping /10
Timely reporting of incidents and unsafe
7. /10
situations
8. Timely reporting of safety violations /10
Outstanding performance, if any, relating with
9. HSE promotional activities /20
(Attach supporting documents) *
Total/100
Nomination and Approval
Supervisor/Engineer Safety Representative
Name Signature Recommendation Name:
Recommended Not Recommended
Comments: Comments: Signature:
Project Manager: Name: Signature: Date:
*Guidelines to criteria for selection:
Suggestions to improve HSE awareness
Encouraging co-workers in HSE
Behaviour during safety meetings
Specific contribution to prevent injuries or property damage
Other specific contribution(s) to Company Health and Safety Programmes.
