<p>Asia South SBU – CHESM Interim and Post-Job Evaluation Form</p><p>1. General Contractor Company Name: Contract/Project Name or Number: Chevron Contract Owner: Number of employees supporting the contract/operations: Company Director/Manager: Contractor Key Personnel: Phone: Email/Fax: </p><p>Site Supervisor: Phone: Email/Fax: </p><p>HES Representative: Phone: Email/ Fax: </p><p>Evaluation Completed by: Name: Position: Phone: Email/Fax Date Submitted: </p><p>2. HES Performance Data</p><p>Provide HES performance data specific to the Chevron Year _____ Year _____ Year _____ project/contract, not to exceed 3 years Total number of employee hours worked Number of work-related fatalities Number of injuries that resulted in restricted work </p><p> activity Number of injuries that resulted in one or more days </p><p> away from work </p><p>Number of injuries and illnesses involving medical </p><p> treatment </p><p>Number of motor vehicle accidents </p><p>Version 1.0.1 July 1st 2007. 1 Printed 17 May 2018. Uncontrolled when printed. 08abdcb6e726c54847c372ca2f5e9bef.doc Asia South SBU – CHESM Interim and Post-Job Evaluation Form</p><p>2. HES Performance Data</p><p>Provide HES performance data specific to the Chevron Year _____ Year _____ Year _____ project/contract, not to exceed 3 years Number of oil and chemical spills </p><p>Annual percent (%) employee turnover rate Have you received any regulatory citation or been involved in any Yes No court litigation in the last three years?</p><p>3. HES Management Systems Improvement Acceptable Comments Needed HES Performance </p><p>1. Safety/Health performance</p><p>2. Environmental performance</p><p>3. Significant events</p><p>4. Annual percent (%) employee turnover rate</p><p>5. Regulatory or court litigation </p><p>HES Management </p><p>1. HES organization</p><p>2. Employee benefits</p><p>3. HES targets</p><p>4. HES written programs</p><p>5. Employee engagement</p><p>6. Safety meetings</p><p>7. Subcontractor management</p><p>8. Inspections and audits</p><p>9. Hazard identification and control</p><p>10. Incident investigation and reporting </p><p>11. Incident corrective action</p><p>2 Version 1.0.1 Revised 1st July 2007. Printed 17 May 2018. Uncontrolled when printed. 08abdcb6e726c54847c372ca2f5e9bef.doc Asia South SBU – CHESM Interim and Post-Job Evaluation Form</p><p>3. HES Management Systems Improvement Acceptable Comments Needed</p><p>12. Sharing of incident learning</p><p>13. Behavior-based safety</p><p>14. Personal protective equipment</p><p>15. Regulatory compliance</p><p>16. Pollution prevention</p><p>17. Emergency preparedness</p><p>Fitness for Duty: Skills, Knowledge and Training </p><p>1. Short -service employees</p><p>2. Craft training</p><p>3. HES orientation</p><p>4. HES training (content)</p><p>5. Training records</p><p>Fitness for Duty (Medical and Industrial Hygiene) </p><p>1. Medical services</p><p>2. Medical examinations</p><p>3. Substance abuse N/A </p><p>4. Industrial hygiene N/A </p><p>Equipment and Materials 1. General 2. Equipment</p><p>Version 1.0. 1 Revised 1st July 2007. 3 Printed 17 May 2018. Uncontrolled when printed. 08abdcb6e726c54847c372ca2f5e9bef.doc Asia South SBU – CHESM Interim and Post-Job Evaluation Form</p><p>4. Action Items Needs Improvement/Not Acceptable Corrective Action Required Target Actual Subject Date Completion</p><p>6.</p><p>7.</p><p>8.</p><p>9.</p><p>10.</p><p>Attach additional sheet if needed.</p><p>Contract Owner: Date reviewed with Contract Owner:</p><p>Corrective actions to be completed by: Contract firm informed Yes No Name informed: Date: of results? Contract firm to remain on re-selection bid list? Yes No Date:</p><p>4 Version 1.0.1 Revised 1st July 2007. Printed 17 May 2018. Uncontrolled when printed. 08abdcb6e726c54847c372ca2f5e9bef.doc</p>