Form Title
Step 1: General Info
Required fields are marked with an asterisk (*).
Step 2: Stakeholder Info
Contract Representative (i.e. Project Manager)
Contractor HSE or designate
EPCOR Owner's Representative & Coordinator
EPCOR HS&E Advisor
Step 3: Contract Companies
Contract Company
(include overtime hours, capture subcontractor hours in separate line item below)
Is the Contract Company listed above Prime Contractor for this report?
Sub - Contractor Companies
Monthly Hours Worked
(including overtime hours)
Total Exposure Hours
(based on monthly hours inputted)
Step 4: Lagging Indicators
Monthly HSE Performance
Other Recordable Incidents - Monthly Total
(restricted/modified work case, loss of consciousness)
Step 5: Lagging Indicators
Required fields are marked with as astrisk (*).
Step 6: Leading Indicators
Required fields are marked with an astrisk (*).
Step 7: Regulatory Actions / Inspections
Required fields are marked with as asterisk (*).
Did your company experience any regulatory stop work orders, actions, demands, or inspections (that required your company to take action as directed by the regulator) this month?