Daily CLOSE CONTACT Declaration
Employee ID number
*
if you are a visitor please put a 'V' otherwise your man number/id
Your Name
*
First Name
Last Name
Department
*
Administration
Contractor
Exploration
HSE&T
Maintenance
Mining Nth Ops / North Mine
Mining Nth Ops / Potosi Mine
Mining Sth Ops
Process
Technical Services
Today's Date
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Month
Year
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Minutes
AM
PM
AM/PM Option
Have you operated any plant, equipment or light vehicles (Equipment) during the shift/workday?
*
Yes
No
Equipment 01
Equipment 02
Equipment 03
Equipment 04
Equipment 05
Equipment 06
Have you had CLOSE CONTACT with another person during the shift/workday?
*
Yes
No
Close Contact 01
Close Contact 02
Close Contact 03
Close Contact 04
Close Contact 05
Close Contact 06
Close Contact 07
Close Contact 08
Close Contact 09
Close Contact 10
I declare the above to be true and correct.
*
Yes.
Submit
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