1. Main contractor name – LTI# - Date of incident 1 Non Accidental Death Name of Company Date of Incident 1

2. Main contractor name – LTI# - Date of incident 2 Incident details PDO directorate/dept: Contractor name/number: Incident owner: Location : Incident date & time:. Incident type: Non Accidental Death (NAD) Actual severity rating: PIM ID: Immediate cause of Death: Previous NAD: Key Latent Mgmt Failure : Name of Company and incident date

3. Main contractor name – LTI# - Date of incident 3 Key information about the Deceased Name of the deceased: DOB and age : Nationality : Marital status and number of children: Duration of service with the company:. HSE trainings and induction: Work schedule and date of last leave: Name of Company and incident date

4. Main contractor name – LTI# - Date of incident 4 On ------------- Summary Description of the incident: Name of Company and incident date

5. Main contractor name – LTI# - Date of incident 5 Sequence of events, during and post incident response – Timeline NoNo DateTimeDescription of event 1 2 3 4 5 6 Name of Company and incident date

6. Main contractor name – LTI# - Date of incident 6  Briefly in few words describe MER response by co-workers/bystanders:  Briefly in few words describe response by First Aiders and how long it took them to reach to the scene:  Briefly in few words describe response by Medics and how long it took them to reach to the scene and use of defibrillator (AED): Description of the Medical Emergency Response (MER) : Name of Company and incident date

7. Main contractor name – LTI# - Date of incident 7  Pre-existing Medical problems and Medications:  Date of Pre-employment and last medical check up and was he declared fit?  Did the deceased attend the clinic or had any complaints before his death during this work period? Past Medical history- Find out about Name of Company and incident date

8. Main contractor name – LTI# - Date of incident 8  Find out about life style issues like smoking habits, alcohol, drugs abuse, exercise activities, dietary habits and obesity :  Find out about his social interactions and relations with colleagues? Life style and social issues Name of Company and incident date

9. Main contractor name – LTI# - Date of incident 9  Find out and investigate if there are any accommodation or work related health hazards eg contact with hazardous substances or poor work environment which could have contributed to the death :  Find out about his social interactions and relations with colleagues? Work Environment and Accommodation conditions Name of Company and incident date

10. Main contractor name – LTI# - Date of incident 10  Find out about the health management in contracts within the direct working Environment of the deceased e.g ( Conduction of health risk assessments, exposure monitoring, health controls, health awareness, MER drills and is Health activities included into the annual HSE plans and are they monitored by contractors and PDO CHs? Contractual Health Management Name of Company and incident date

11. Main contractor name – LTI# - Date of incident 11 Key investigation findings: List all the important findings 1. Name of Company and incident date

12. Main contractor name – LTI# - Date of incident 12 Conclusions: Name of Company and incident date Immediate Cause of Death:............. Underlying Causes of Death: It was not possible to definitively establish the underlying causes, however based on circumstantial evidence the following is possible: Latent management Failure: AAAAAAAAAAAAAA

13. Main contractor name – LTI# - Date of incident 13 Immediate Remedial actions taken if any: S. No. Actions Date of actionStatus 1 Informed Site Management PDO emergency and ROP/ RSST. PDO on seen commander taken over the site Closed 2 PDO medical team arrived and body shifted to PDO clinic. Closed 3 Name of Company and incident date

14. Main contractor name – LTI# - Date of incident 14 Essential Recommendations: NORecommendations(Actions)Target DateAction Party (Contractor) Action Party (PDO) Status 1 2 3 Name of Company and incident date

15. Main contractor name – LTI# - Date of incident 15 Date : ………… – NAD incident What happened? Your learning from this incident... PDO Safety Advice

16. Main contractor name – LTI# - Date of incident 16  Do you report and investigate all occupational illnesses and NADs?  Are you using a PDO approved clinics for conducting PDO specific fitness to work medical examinations? and do your medical staff review and scrutinize the submitted reports to confirm conformance to PDO standards?  Are all your staff up to date with their periodic medical check?  Do you track and keep list of all employees with chronic medical conditions such as diabetes, high BP etc  Do you obtain timely medical waiver for your employees who are above 60 years of age?  Do you obtain PDO medical department approval and familiarization for your medical staff prior to deployment to PDO sites?  Is health management within the direct working environment of the deceased meeting Company standards? And do you encourage your staff to seek medical help if feeling unwell?  Do you ensure calibration of Medical equipments including AED and carry out daily ambulance inspection ?  Do your medics attend regular continuous medical education sessions and have valid MOH license and ACLS certification?  Do you have MER plan and do you conduct medical drills?  Do you have a clear Alcohol and drugs policy?  Do you submit to PDO the monthly health performance report?  Do you conduct regular health awareness to your staff?  Is health activities included into the annual HSE plans? Health Management CHECK List - Please confirm Name of Company and incident date