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Form Title

Step 1: General Info

Required fields are marked with an asterisk (*).

Month

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Year

2023 2024 2025 2026 2027 2028

Business Area

Corporate Services Electricity Services NA Commercial Services Regulated US Water Water Services

Electricity Services Location

CETR Customer Connections Distribution Engineering Facilities Transmission Other

NA Commercial Services Location

CA Commercial Operations CA Commercial Services Ontario Operations Technologies/Fleet US Commercial Operations US Gas Operations

Regulated US Water Location

Water Treatment Plants Wastewater Treatment Plants Water D&T WastewaterCollection

Water Service Location

Gold Bar WWTP Water Treatment Plants Water D&T Wastewater Collection (drainage services)

Project Name

Project Number

Step 2: Stakeholder Info

Required fields are marked with an asterisk (*).

Contract Representative (i.e. Project Manager)

Name

Email Address

Contractor HSE or designate

Name

Email Address

EPCOR Owner's Representative & Coordinator

Name

Email Address

EPCOR HS&E Advisor

Name

Step 3: Contract Companies

Required fields are marked with an asterisk (*).

Contract Company

Company Name

Monthly Hours Worked

(include overtime hours, capture subcontractor hours in separate line item below)

Prime Contractor?

Yes

No

Is the Contract Company listed above Prime Contractor for this report?

Sub - Contractor Companies

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

+ ADD SUB-CONTRACTOR

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

+ ADD SUB-CONTRACTOR

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

+ ADD SUB-CONTRACTOR

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

+ ADD SUB-CONTRACTOR

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

+ ADD SUB-CONTRACTOR

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

+ ADD SUB-CONTRACTOR

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

+ ADD SUB-CONTRACTOR

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

+ ADD SUB-CONTRACTOR

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

+ ADD SUB-CONTRACTOR

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

+ADD SUB-CONTRACTOR

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

+ ADD SUB-CONTRACTOR

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

+ ADD SUB-CONTRACTOR

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

+ ADD SUB-CONTRACTOR

Company Name

Monthly Hours Worked

(including overtime hours)

Are your subcontractors greater than or equal to 51% indigenous owned?

No

Yes

Enter total amount spent this month:

---

+ ADD SUB-CONTRACTOR

+ ADD SUB-CONTRACTOR

Total Exposure Hours

(based on monthly hours inputted)

Monthly Indigenous Subcontractor spend total ($)

Step 4: Lagging Indicators

Required fields are marked with an asterisk (*).

Monthly HSE Performance

# of Near Misses - Monthly Total

Provide incident dates and details here.

# of On-site First Aid - Monthly Total

Provide incident dates and details here.

# of Off-site First Aid - Monthly Total

Provide incident dates and details here.

# of Medical Treatments - Monthly Total

Provide incident dates and details here.

# of Lost Time - Monthly Total

Provide incident dates and details here.

# of Lost Work Days - Monthly Total

Provide incident dates and details here.

---

Other Recordable Incidents - Monthly Total

(restricted/modified work case, loss of consciousness)

Provide incident dates and details here.

---

# of Restricted / Modified Work Days - Monthly Total

Provide first date of restricted/modified work.

Step 5: Lagging Indicators

Required fields are marked with as astrisk (*).

Monthly HSE Performance

# of Environmental Incidents - Monthly Total

Provide incident dates and details here.

---

# of Vehicle incidents - Monthly Total

Provide Incident dates and details here.

---

# of Utility Strikes - Monthly Total

Provide incident dates and details here.

---

# of Property Damage - Monthly Total

Provide incident dates and details here.

---

# of Other (security incidents, etc.) - Monthly Total

Provide incident dates and details here.

---

Step 6: Leading Indicators

Required fields are marked with an astrisk (*).

Monthly HSE Performance

Toolbox Talks / FLHAs - Monthly Total

Safety Meetings - Monthly Total

EPCOR Orientations - Monthly Total

Safety Inspections - Monthly Total

Safety Observations - Monthly Total

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?

Yes

No

Provide the regulatory agency and description of action taken.

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