# Form 04 — Monthly Attestation and Incident Reconciliation

**Complete once per benchmark site and reporting month. Submit with the monthly worker-hour register and, where applicable, subcontractor annexes and the exception log.**

## A. Submission identity

| Field | Required entry |
|---|---|
| Template version | `1.0` |
| Benchmark site ID | Assigned site ID |
| Reporting month | `YYYY-MM` |
| Submission ID | Unique controlled reference, e.g. `SSU-BENCH-YYYYMM-XXX` |
| Register submitted by | Name, role, business email |
| HSE data certifier | Name, role, business email |
| Submission date | `YYYY-MM-DD` |
| New submission or correction | New / corrected. If corrected, state previous submission ID and reason. |

## B. Worker-hour summary

Copy the totals from the consolidated register. The benchmark administrator recalculates these fields from the CSV; differences require correction.

| Workforce category | Worker-hours | Number of non-overlapping workforce-group rows | Source-supported hours | Estimated hours |
|---|---:|---:|---:|---:|
| Direct employees |  |  |  |  |
| Labour-supply workers |  |  |  |  |
| Subcontractor workers |  |  |  |  |
| Site office / management, if in scope |  |  |  |  |
| Other in-scope group |  |  |  |  |
| **Total** |  |  |  |  |

| Required reconciliation | Response |
|---|---|
| Total register worker-hours |  |
| Total source-supported worker-hours |  |
| Total estimated worker-hours |  |
| Estimated share = estimated hours ÷ total worker-hours |  % |
| All active in-scope groups have a register row or exception? | Yes / No |
| Any worker-hours duplicated across direct/labour-supply/subcontractor groups? | Yes / No |
| If the site was inactive, does the submission show zero actual worker-hours and an inactive status in notes? | Yes / No / Not applicable |

## C. Incident population reconciliation

| Question | Required response |
|---|---|
| Does the incident register cover the same workforce groups and project boundary as the worker-hour register? | Yes / No. If no, open an exception. |
| Number of benchmark-recordable cases identified for the month before final classification |  |
| Number of cases pending classification or late follow-up |  |
| Number of cases connected to a workforce group missing from worker-hour coverage |  |
| Is this a verified zero-incident month? | Yes / No. If yes, HSE certifier must confirm below. |
| Incident-register source reference, private |  |
| Reconciliation completed by | Name and role |
| Reconciliation completion date | `YYYY-MM-DD` |

## D. Source and exception declaration

| Question | Required response |
|---|---|
| Primary source used for direct labour hours |  |
| Number of certified subcontractor annexes received |  |
| Number of active subcontractor groups without a return |  |
| Exception-log IDs submitted | `EXC-001`, etc., or None |
| Any system outage, late return, estimate, scope change, or correction affecting this month? | Yes / No; if yes, list exception ID(s). |
| Does the month meet the 95% source-supported / maximum 5% estimated eligibility standard? | Yes / No / Pending benchmark review |

## E. Certifier declaration

Initial each statement and sign the authorisation.

- [ ] The submitted worker-hours refer to actual work performed during the stated month by the covered workforce at the benchmark site.
- [ ] The worker-hour and incident populations are the same, except where a disclosed exception states otherwise.
- [ ] Workforce groups are mutually exclusive and have not been submitted to the benchmark through another site or employer ledger.
- [ ] Every estimate, late return, data gap, and scope change is identified in the exception log.
- [ ] The register contains no individual worker names, identity documents, contact information, medical information, photos, or incident narratives.
- [ ] Supporting records are retained by the site data owner and can be made available for a controlled audit, subject to approved privacy procedures.
- [ ] I understand that the benchmark may exclude this site-month from primary rate calculations if the data-quality standard is not met.

| Site data owner: name, role, controlled approval/signature | HSE data certifier: name, role, controlled approval/signature | Date |
|---|---|---|
|  |  | `YYYY-MM-DD` |