FORM G HEALTH, SAFETY AND ENVIRONMENTAL – PERFORMANCE FORM G HEALTH, SAFETY AND ENVIRONMENTAL PERFORMANCE – [TO BE COMPLETED FOR EACH MEMBER IN JV/CONSORTIUM] Date: [insert day, year] Ref: Doha Metro and Lusail Tram Railway Operator Contracts Page: [x] of [y] 1. Applicant’s legal name (same as Form B (1)): 2. Applicant member’s name (as per Form B (2)): Qatar Rail Use Only Contracts Approved __ Yes __ No Health, Safety and Environmental Performance ESH Approved __ Yes __ Prequalification Questionnaire No Project Approved __ Yes __ No 1. COMPANY NAME Name: Telephone #: ( ) ( ) Address: Fax #: E-mail Address: Person Completing this Form: 2. Type of Work: Mechanical Operation of Works Trains Electrical Work Other (State Type): 3. Injury and Citation/Prosecution History 3.1 What is your injury information for the three most recent years: 2012 2013 2014 Number of fatalities b. Number of lost-time injuries and illnesses cases c. Number of days away from work for injury or illness
FORM G – HEALTH, SAFETY AND ENVIRONMENTAL PERFORMANCE FORM G – HEALTH, SAFETY AND ENVIRONMENTAL PERFORMANCE [TO BE COMPLETED FOR EACH MEMBER IN JV/CONSORTIUM] Date: [insert day, year] Ref: Doha Metro and Lusail Tram Railway Operator Contracts Page: [x] of [y] 1. Applicant’s legal name (same as Form B (1)): 2. Applicant member’s name (as per Form B (2)): Health, Safety and Environmental Performance Prequalification Questionnaire Qatar Rail Use Only Contracts Approved __ Yes __ No ESH Approved __ Yes __ No Project Approved __ Yes __ No 1. COMPANY NAME Name: Telephone #: ( ) Address: Fax #: ( ) E-mail Address: Person Completing this Form: 2. Type of Work: Mechanical Operation of Works Trains Electrical Work Other (State Type): 3. Injury and Citation/Prosecution History 3.1 What is your injury information for the three most recent years: 2012 2013 2014 Number of fatalities b. Number of lost-time injuries and illnesses cases c. Number of days away from work for injury or illness