Form Csms.xlsx 3g74b
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CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES
1. Nama Perusahaan / Company Name
:
2. Bidang Pekerjaan / Work Field
3. Peralatan yang Digunakan / Equipments Used
:
:
□ Perkakas Tangan / Hand Tools □ Alat Berat / Heavy Equipments (Dozer, Excavator, Compactor, Grader)
□ Trailer, Lowboy □ Truk / Truck □ Crane 4. Material yang Digunakan / Materials Used
□ Tangga / Stairs □ Rigging/Hoisting □ Kompresor / Compressor □ Scaffolding
:
□ Bahan Kimia Berbahaya / Hazardous Chemicals □ Bahan Peledak / Explosive Materials □ Bahan Radioaktif / Radioactive Materials 5. Lingkup Pekerjaan / Scope of Work
□ Mesin Las / Welding Machine
□ ... □ ... □ ...
:
Catatan: jika lebih dari satu jenis pekerjaan, maka pastikan Anda melampirkan dokumen CSMS yang diminta seperti prosedur, pelat dengan masing-masing jenis pekerjaan.
Note: if more than one kind of work, you shall to attached CSMS documents as requested such as procedure, training, and certifica work
□ Fabricator □ Forwarder □ Offshore □ Diving □ Pipe Laying □ Trenching of Dredging □ Architectural Work □ Instrument
□ Batching Plant □ Coating & Painting □ Concrete & Foundation Activity □ Drainage □ Scaffolding □ Barge & Vessel Owner □ Deepwell Activity □ Piling
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES
□ Insulation □ Land Clearing □ Logging □ Mechanical □ Medical Services Provider □ NDT - Radiography
□ Plumbing □ Portacamp Mob. & Lifting □ Raw Water Intake Work □ Roofing & Siding □ Security Service □ Soil Investigation
Catatan / Note: NO.1 s/d 5 harus diisi oleh Perusahaan yang mengajukan penilaian CSMS / No.1 to 5 shall be completted b
Nama / Name Tgl / Date
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES NO I
KUESIONER / QUESTIONNAIRE EVIDENCE / LAMPIRAN BUKTI KEPEMIMPINAN & KEBIJAKAN K3LL / LEADERSHIP & HSE POLICY
Apakah perusahaan Anda memiliki kebijakan K3LL, terdokumentasi & ditandatangani oleh pimpinan 1 perusahaan?
Salinan kebijakan K3LL perusahaan
Does your company have HSE Policy, documented & approved Copy of HSE policy by Company Leader?
Bagaimana cara perusahaan Anda mensosialisasikan kebijakan K3LL? 2
How does your company socialize the HSE policy?
Bukti sosialisasi: daftar hadir dan materi orientasi pekerja / tamu (sebagai tambahan dapat melampirkan poster kebijakan, banner) Socialization evidences: attendance list and orientation materials (in addition please attach poster, banner)
3
Siapakah orang yang bertanggung jawab dalam penerapan sistem manajemen K3LL di perusahaan Anda?
Riwayat kerja orang yang bertanggung jawab dalam penerapan sistem manajemen K3LL di perusahaan
Who is the responsible person for implementing the HSE management system at your company?
CV of the responsible person for implementing the HSE management system at the company
Jelaskan bagaimana keterlibatan pemimpin perusahaan Anda terkait dengan penerapan sistem manajemen 4 K3LL? Please, explain the involvement of your company leader regarding HSE management system implementation?
Notulensi rapat P2K3 mengenai peninjauan ulang sistem manajemen K3LL P2K3 minutes of meeting about review of HSE management system
NILAI TOTAL / TOTAL SCORE KEPATUHAN TERHADAP PERATURAN PERUNDANGAN K3LL / HSE REGULATION COMPLIANCE II Apakah perusahaan Anda memiliki organisasi P2K3 dan Struktur organisasi dilengkapi dengan LL? nama 1
2
Does your company have HSE committee organization?
Complete organization chart with name
Sebutkan tugas dan tanggung jawab masing-masing personil dalam penerapan sistem manajemen K3LL di perusahaan Anda?
Tugas dan tanggung jawab masing-masing personil dalam penerapan sistem manajemen K3LL
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES 2 Please, explain the job description of each personnel regarding Job description of each personnel in HSE HSE management system implementation at your company? management system implementation
Apakah perusahaan Anda memiliki HSE personil yang kompeten untuk memberikan panduan dalam program 3 K3LL?
Riwayat pekerjaan serta sertifikasi (Depnaker / Migas) pimpinan HSE personil
Does your company have competent HSE personnel that drive CV and certification (Depnaker / Migas the HSE program? certification) of HSE leader
4
Apakah perusahaan Anda melakukan pemeriksaan kesehatan secara berkala?
Catatan hasil MCU dan rekapitulasi
Does your company carry out the Medical Check Up regularly? MCU record and recapitulation
5
Apakah perusahaan Anda memiliki program Jamsostek / Salinan kartu Jamsostek / asuransi asuransi kesehatan dan kecelakaan? kesehatan dan kecelakaan Does your company have Jamsostek / health and accident insurance program?
Copy of Jamsostek / health and accident insurance card
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES
Apakah perusahaan Anda memiliki personel kunci yang kompeten sesuai lingkup pekerjaan?
Riwayat pekerjaan dan sertifikasi keahlian kerja (contoh: sertifikasi welder, SIO peralatan berat, dll)
Does your company have competent key personnel related to the scope of work?
CV and certification of job skills (e.g. welder certification, heavy vehicle license, etc.)
Apakah perusahaan Anda mengelola peralatan operasi dengan mematuhi ketentuan dari pihak berwenang (sertifikasi, kalibrasi)?
Sertifikat alat berat, kalibrasi peralatan, atau lainnya
Does your company manage operation equipments comply with regulations (calibration, certification)?
Heavy vehicle certification, equipment calibration or etc.
6
7
NILAI TOTAL / TOTAL SCORE PELATIHAN / TRAINING III
Apakah perusahaan Anda memiliki program dan memberikan pelatihan K3LL secara internal / eksternal?
Salinan prosedur pelatihan K3LL,matrix pelatihan, daftar hadir, materi pelatihan internal (contoh: pelatihan APD, Bekerja di ketinggian, pelatihan pengelolaan bahan kimia, HSE induksi, dll)
Does your company have program and give HSE internal / external training?
Attendance list, copy of HSE training procedure, and training materials (e.g. PPE training, chemical handling, induction, etc.)
1
2
Apakah perusahaan Anda memberikan pelatihan kepada Matriks dan sertifikat pelatihan bidang karyawan sesuai dengan lingkup pekerjaan? keahlian kerja Does your company give training to employee related to the scope of work?
Matrix and training certificate of work skill
NILAI TOTAL / TOTAL SCORE MANAJEMEN SUBKONTRAKTOR / MANAGEMENT OF SUBCONTRACTOR IV
1
2
Bagaimana perusahaan Anda mengelola subkontraktor yang dapat mendukung program K3LL perusahaan?
Salinan prosedur pengelolaan subkontraktor / CSMS
How does your company manage subcontractor for company HSE program?
Copy of subcontractor management procedure / CSMS
Bagaimana perusahaan Anda memastikan bahwa subkontraktor memahami dan melaksanakan program K3LL?
Hasil evaluasi subkontraktor / dokumen kontrak yang memuat aspek K3LL
How does your company ensure that subcontractor understand Subcontractor evaluation result / contract and implement HSE program? document that mention the HSE aspect
NILAI TOTAL / TOTAL SCORE
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES
HSE DALAM DESAIN, KONSTRUKSI, DAN KOMISIONING / HSE IN DESIGN, CONSTRUCTION, AND COMISS
V
1
Apakah perusahaan Anda memiliki prosedur kerja sesuai Daftar dan salinan prosedur kerja sesuai dengan lingkup pekerjaan? dengan lingkup pekerjaan Does your company have working procedure related to the scope of work?
Apakah perusahaan Anda memiliki rencana program 2 K3LL untuk pelaksanaan proyek?
3
4
List and copy of working procedure related to the scope of work
Salinan rencana program K3LL
Does your company have HSE plan for project execution?
Copy of HSE plan
Apakah perusahaan Anda memiliki prosedur identifikasi bahaya dan penilaian risiko?
Salinan prosedur identifikasi bahaya dan penilaian risiko (JSA, RA)
Does your company have hazard identification and risk assesment procedure?
Copy of hazard identification and risk assesment procedure (JSA, RA)
Apakah perusahaan Anda memiliki contoh JSA dan RA sesuai dengan detail / lingkup pekerjaan?
Contoh JSA dan RA sesuai dengan detail / lingkup pekerjaan
Does your company have an example of JSA and RA related to Example of JSA and RA related to the detail / the detail / scope of work? scope of work
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES Apakah perusahaan Anda memiliki prosedur Izin Kerja 5 Aman? Does your company have Permit to Work procedure?
6
Salinan prosedur Izin Kerja Aman Copy of Permit to Work procedure
Salinan prosedur APD (perawatan, Apakah perusahaan Anda memiliki prosedur tentang APD penyimpanan, dll) dan daftar APD sesuai dan membuat daftar APD sesuai spesifikasi lingkup dengan lingkup pekerjaan (jenis dan pekerjaan? spesifikasi sesuai standar nasional / internasional)
Does your company have PPE procedure and make a list of PPE and specification related to the scope of work?
Bagaimana perusahaan Anda memastikan APD telah diterima oleh karyawan sesuai dengan lingkup 7 pekerjaan?
Copy of PPE procedure (maintenance, storage, etc.) and list of PPE related to the scope of work (type and specification according to national / international standards)
Catatan distribusi dan inventarisasi APD
How does your company ensuring PPE accept properly by worker related to the scope of work?
PPE distribution record and inventory
Apakah perusahaan Anda memiliki program Higiene Industri? (pencahayaan, debu, suhu, ergonomi, dll)
Laporan pengukuran Higiene Industri
Does your company have Industrial Hygiene program? (illumination, dust, temperature, ergonomic, etc.)
Industrial Hygiene measurement report
Apakah perusahaan Anda memiliki prosedur pengendalian tumpahan bahan kimia?
Salinan prosedur pengendalian tumpahan bahan kimia
Does your company have chemical spill handling procedure?
Copy of chemical spill handling procedure
8
9
Apakah perusahaan Anda memiliki prosedur pengelolaan Salinan prosedur pengelolaan limbah limbah? 10
11
Does your company have waste management procedure?
Copy of waste management procedure
Bagaimana cara perusahaan Anda menangani limbah B3? (oli bekas, tumpahan minyak, material B3 kadaluarsa, pelarut, dll)
Manifest limbah B3
How does your company handle hazardous waste? (used oil, oil spill, expired hazardous material, solvent, etc.)
Manifest of hazardous waste
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES NILAI TOTAL / TOTAL SCORE MANAJEMEN PERUBAHAN / MANAGEMENT OF CHANGE VI Apakah perusahaan Anda memiliki prosedur manajemen Salinan prosedur manajemen perubahan perubahan? 1 Does your company have management of change procedure? Copy of management of change procedure
Bagaimana cara perusahaan Anda melakukan manajemen perubahan?
Salinan form manajemen perubahan (contoh: perubahan struktur organisasi perusahaan, perubahan penggunaan peralatan di tempat kerja, dll)
How does your company perform management of change?
Copy of management of change form (e.g. organizational-structural change, equipment change, etc.)
2
NILAI TOTAL / TOTAL SCORE INSPEKSI / INSPECTION VII Apakah perusahaan Anda melakukan inspeksi umum tempat kerja? 1
Does your company carry out the general workplace inspection?
Bukti inspeksi K3LL (min: 2 periode inspeksi)
Evidence of HSE inspection (min: 2 inspection periods)
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES Bagaimana cara perusahaan Anda untuk menindak lanjuti Laporan tindak lanjut hasil temuan temuan inspeksi? 2 How does your company follow up the inspection findings?
Report of follow up inspection finding
Apakah peralatan kerja Anda diinspeksi sebelum dikirim ke lokasi proyek (mobilisasi)?
Bukti hasil inspeksi peralatan
Does your company equipments inspected before sent to project site area (mobilization)?
Evidence of equipment inspection results
3
Apakah perusahaan Anda melakukan inspeksi pada alat Jadwal dan hasil inspeksi alat kerja kerja yang digunakan? 4 Does your company do inspection for working equipments?
Equipment inspection schedule and result
NILAI TOTAL / TOTAL SCORE KOMUNIKASI / COMMUNICATION VIII
1
2
3
Apakah perusahaan Anda melakukan rapat toolbox / safety talk?
Daftar hadir dan materi rapat toolbox / safety talk
Does your company carry out toolbox / safety talk meeting program?
Attendance list and materials of toolbox / safety talk meeting
Apakah perusahaan Anda mengkomunikasikan Job Safety Analysis / Risk Assessment?
Daftar hadir komunikasi JSA / RA
Does your company communicate Job Safety Analysis / Risk Assessment?
Attendance list JSA / RA communication
Apakah perusahaan Anda memiliki sarana komunikasi K3LL lainnya? (HSE news, HSE bulletin, HSE Alert dll)
Contoh HSE news, HSE bulletin, HSE Alert dll
Does your company have other HSE communication tool? (HSE news, HSE bulletin, HSE Alert etc.)
Example of HSE news, HSE bulletin, HSE Alert etc.
NILAI TOTAL / TOTAL SCORE TANGGAP DARURAT / EMERGENCY RESPONSE IX Apakah perusahaan Anda memiliki prosedur emergensi? Salinan prosedur emergensi 1 Does your company have emergency procedure?
Copy of emergency procedure
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES Apakah perusahaan Anda melakukan pelatihan 2 emergensi secara berkala? Does your company do the emergency drill regularly?
Laporan pelatihan emergensi Emergency drill report
NILAI TOTAL / TOTAL SCORE PELAPORAN DAN PENYELIDIKAN KEJADIAN KECELAKAAN DAN PENCEMARAN LINGKUNGAN / X REPORTING AND INVESTIGATION OF INCIDENT AND ENVIRONMENTAL POLLUTION 1
Apakah perusahaan Anda memiliki prosedur pelaporan kecelakaan kerja?
Salinan prosedur pelaporan kecelakaan kerja
Does your company have incident reporting procedure?
Copy of incident reporting procedure
Apakah perusahaan Anda mencatat statistik kecelakaan dalam 3 tahun terakhir? (LTIFR, LTISR, dll)
Statistik kecelakaan tiga tahun terakhir (jika ada, mohon lampirkan contoh laporan investigasi kecelakaan)
Does your company record the accident statistic for last 3 years? (LTIFR, LTISR, etc.)
Accident statistic report for last 3 years (if available, please attach example of accident investigation report)
2
XI
NILAI TOTAL / TOTAL SCORE DOKUMENTASI / DOCUMENTATION Kumpulan daftar dokumen, salinan Bagaimana cara perusahaan Anda mendokumentasikan prosedur pendokumentasian, dan lembar dan memperbaharui program K3LL? revisi 1 How does your company document and renew the HSE program?
NILAI TOTAL / TOTAL SCORE
Master list of HSE document, copy of document control prosedur, and historical sheet
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES XII
EVALUASI / EVALUATION Apakah perusahaan Anda memiliki prosedur evaluasi 1 K3LL?
Salinan prosedur evaluasi K3LL
Does your company have HSE evaluation procedure?
Copy of HSE evaluation procedure
Apakah perusahaan Anda melakukan internal audit K3LL?
Jadwal dan laporan hasil internal audit K3LL
Does your company carry out HSE internal audit?
Schedule and report of HSE internal audit
Apakah perusahaan Anda memiliki sertifikat sistem manajemen K3LL dari pemerintah / badan sertifikasi?
Salinan sertifikat OHSAS 18001: 2007, ISO 14001: 2004, SMK3, penghargaan jam kerja aman, dll
Does your company have HSE management system certification from government / certification agencies?
Copy certificate of OHSAS 18001:2007, ISO 14001: 2004, SMK3, reward for zero accident, etc.)
2
3
NILAI TOTAL / TOTAL SCORE REWARD DAN PUNISHMENT / REWARD AND PUNISHMENT XIII Apakah perusahaan Anda memiliki prosedur tentang Salinan prosedur promosi / reward HSE promosi / reward HSE? 1 How does your company have HSE promotion / reward procedure?
Copy of HSE promotion / reward procedure
Bagaimana perusahaan Anda menerapkan program reward dan punishment HSE?
Salinan penghargaan atau pemberian hadiah kepada pekerja Salinan sangsi disiplin kepada pekerja mengenai pelanggaran K3LL
How does your company implement HSE reward and punishment program?
Copy of reward for worker Copy of punishment for worker regarding HSE violation
2
NILAI TOTAL / TOTAL SCORE NILAI TOTAL KESELURUHAN / TOTAL SCORE OVERALL
Minimal Skor kelulusan Offshore 70 Minimal Skor kelulusan High Risk 60 Minimal Skor kelulusan Low Risk 50
PT………. HAS ED THE QUALIFICATI Prepared by, date…………
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES
HSE Engineer
YSTEM QUESTIONNAIRE
□ Mesin Pilling / Pilling Machine □ Pompa / Pumps □ Kapal Laut / Vessel □… □…
ti prosedur, pelatihan, dan sertifikasi sesuai
ning, and certification related to each kind of
□ Earth Work & Earth Moving □ Chemical Cleaning □ Electrical □ Cathodic Protection Activity □ Post Trenching □ Weather Forecast Activity □ HVAC Installation □ Steel Structure
YSTEM QUESTIONNAIRE
□ Temporary Facility □ Topography □ Transportation Provider □… □… □…
shall be completted by Company who propose CSMS assessment
Perwakilan Perusahaan, Company Representative,
: :
YSTEM QUESTIONNAIRE NILAI / SCORE BOBOT / WEIGHT
0
2
0
2
0
2
0
2
0
8
0
2
0
2
ANCE
KETERANGAN / REMARK
YSTEM QUESTIONNAIRE 0
2
0
3
0
2
0
2
YSTEM QUESTIONNAIRE
0
2
0
2
0
15
0
4
0
2
0
6
0
2
0
2
0
4
YSTEM QUESTIONNAIRE
N, AND COMISSIONING
0
2
0
4
0
2
2
YSTEM QUESTIONNAIRE
0
2
0
2
0
2
0
2
0
2
0
2
0
2
YSTEM QUESTIONNAIRE 0
24
0
2
0
2
0
4
0
2
YSTEM QUESTIONNAIRE
0
2
0
2
0
2
0
8
0
2
0
2
0
2
0
6
0
3
YSTEM QUESTIONNAIRE
0
3
0
6
0
2
0
2
0
4
0
2
0
2
NGAN /
YSTEM QUESTIONNAIRE
0
3
0
3
0
3
0
9
0
2
0
2
0
4
0
100
UALIFICATION Reviewed by,
YSTEM QUESTIONNAIRE
HSE Senior Engineer
1. Nama Perusahaan / Company Name
:
2. Bidang Pekerjaan / Work Field
3. Peralatan yang Digunakan / Equipments Used
:
:
□ Perkakas Tangan / Hand Tools □ Alat Berat / Heavy Equipments (Dozer, Excavator, Compactor, Grader)
□ Trailer, Lowboy □ Truk / Truck □ Crane 4. Material yang Digunakan / Materials Used
□ Tangga / Stairs □ Rigging/Hoisting □ Kompresor / Compressor □ Scaffolding
:
□ Bahan Kimia Berbahaya / Hazardous Chemicals □ Bahan Peledak / Explosive Materials □ Bahan Radioaktif / Radioactive Materials 5. Lingkup Pekerjaan / Scope of Work
□ Mesin Las / Welding Machine
□ ... □ ... □ ...
:
Catatan: jika lebih dari satu jenis pekerjaan, maka pastikan Anda melampirkan dokumen CSMS yang diminta seperti prosedur, pelat dengan masing-masing jenis pekerjaan.
Note: if more than one kind of work, you shall to attached CSMS documents as requested such as procedure, training, and certifica work
□ Fabricator □ Forwarder □ Offshore □ Diving □ Pipe Laying □ Trenching of Dredging □ Architectural Work □ Instrument
□ Batching Plant □ Coating & Painting □ Concrete & Foundation Activity □ Drainage □ Scaffolding □ Barge & Vessel Owner □ Deepwell Activity □ Piling
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES
□ Insulation □ Land Clearing □ Logging □ Mechanical □ Medical Services Provider □ NDT - Radiography
□ Plumbing □ Portacamp Mob. & Lifting □ Raw Water Intake Work □ Roofing & Siding □ Security Service □ Soil Investigation
Catatan / Note: NO.1 s/d 5 harus diisi oleh Perusahaan yang mengajukan penilaian CSMS / No.1 to 5 shall be completted b
Nama / Name Tgl / Date
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES NO I
KUESIONER / QUESTIONNAIRE EVIDENCE / LAMPIRAN BUKTI KEPEMIMPINAN & KEBIJAKAN K3LL / LEADERSHIP & HSE POLICY
Apakah perusahaan Anda memiliki kebijakan K3LL, terdokumentasi & ditandatangani oleh pimpinan 1 perusahaan?
Salinan kebijakan K3LL perusahaan
Does your company have HSE Policy, documented & approved Copy of HSE policy by Company Leader?
Bagaimana cara perusahaan Anda mensosialisasikan kebijakan K3LL? 2
How does your company socialize the HSE policy?
Bukti sosialisasi: daftar hadir dan materi orientasi pekerja / tamu (sebagai tambahan dapat melampirkan poster kebijakan, banner) Socialization evidences: attendance list and orientation materials (in addition please attach poster, banner)
3
Siapakah orang yang bertanggung jawab dalam penerapan sistem manajemen K3LL di perusahaan Anda?
Riwayat kerja orang yang bertanggung jawab dalam penerapan sistem manajemen K3LL di perusahaan
Who is the responsible person for implementing the HSE management system at your company?
CV of the responsible person for implementing the HSE management system at the company
Jelaskan bagaimana keterlibatan pemimpin perusahaan Anda terkait dengan penerapan sistem manajemen 4 K3LL? Please, explain the involvement of your company leader regarding HSE management system implementation?
Notulensi rapat P2K3 mengenai peninjauan ulang sistem manajemen K3LL P2K3 minutes of meeting about review of HSE management system
NILAI TOTAL / TOTAL SCORE KEPATUHAN TERHADAP PERATURAN PERUNDANGAN K3LL / HSE REGULATION COMPLIANCE II Apakah perusahaan Anda memiliki organisasi P2K3 dan Struktur organisasi dilengkapi dengan LL? nama 1
2
Does your company have HSE committee organization?
Complete organization chart with name
Sebutkan tugas dan tanggung jawab masing-masing personil dalam penerapan sistem manajemen K3LL di perusahaan Anda?
Tugas dan tanggung jawab masing-masing personil dalam penerapan sistem manajemen K3LL
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES 2 Please, explain the job description of each personnel regarding Job description of each personnel in HSE HSE management system implementation at your company? management system implementation
Apakah perusahaan Anda memiliki HSE personil yang kompeten untuk memberikan panduan dalam program 3 K3LL?
Riwayat pekerjaan serta sertifikasi (Depnaker / Migas) pimpinan HSE personil
Does your company have competent HSE personnel that drive CV and certification (Depnaker / Migas the HSE program? certification) of HSE leader
4
Apakah perusahaan Anda melakukan pemeriksaan kesehatan secara berkala?
Catatan hasil MCU dan rekapitulasi
Does your company carry out the Medical Check Up regularly? MCU record and recapitulation
5
Apakah perusahaan Anda memiliki program Jamsostek / Salinan kartu Jamsostek / asuransi asuransi kesehatan dan kecelakaan? kesehatan dan kecelakaan Does your company have Jamsostek / health and accident insurance program?
Copy of Jamsostek / health and accident insurance card
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES
Apakah perusahaan Anda memiliki personel kunci yang kompeten sesuai lingkup pekerjaan?
Riwayat pekerjaan dan sertifikasi keahlian kerja (contoh: sertifikasi welder, SIO peralatan berat, dll)
Does your company have competent key personnel related to the scope of work?
CV and certification of job skills (e.g. welder certification, heavy vehicle license, etc.)
Apakah perusahaan Anda mengelola peralatan operasi dengan mematuhi ketentuan dari pihak berwenang (sertifikasi, kalibrasi)?
Sertifikat alat berat, kalibrasi peralatan, atau lainnya
Does your company manage operation equipments comply with regulations (calibration, certification)?
Heavy vehicle certification, equipment calibration or etc.
6
7
NILAI TOTAL / TOTAL SCORE PELATIHAN / TRAINING III
Apakah perusahaan Anda memiliki program dan memberikan pelatihan K3LL secara internal / eksternal?
Salinan prosedur pelatihan K3LL,matrix pelatihan, daftar hadir, materi pelatihan internal (contoh: pelatihan APD, Bekerja di ketinggian, pelatihan pengelolaan bahan kimia, HSE induksi, dll)
Does your company have program and give HSE internal / external training?
Attendance list, copy of HSE training procedure, and training materials (e.g. PPE training, chemical handling, induction, etc.)
1
2
Apakah perusahaan Anda memberikan pelatihan kepada Matriks dan sertifikat pelatihan bidang karyawan sesuai dengan lingkup pekerjaan? keahlian kerja Does your company give training to employee related to the scope of work?
Matrix and training certificate of work skill
NILAI TOTAL / TOTAL SCORE MANAJEMEN SUBKONTRAKTOR / MANAGEMENT OF SUBCONTRACTOR IV
1
2
Bagaimana perusahaan Anda mengelola subkontraktor yang dapat mendukung program K3LL perusahaan?
Salinan prosedur pengelolaan subkontraktor / CSMS
How does your company manage subcontractor for company HSE program?
Copy of subcontractor management procedure / CSMS
Bagaimana perusahaan Anda memastikan bahwa subkontraktor memahami dan melaksanakan program K3LL?
Hasil evaluasi subkontraktor / dokumen kontrak yang memuat aspek K3LL
How does your company ensure that subcontractor understand Subcontractor evaluation result / contract and implement HSE program? document that mention the HSE aspect
NILAI TOTAL / TOTAL SCORE
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES
HSE DALAM DESAIN, KONSTRUKSI, DAN KOMISIONING / HSE IN DESIGN, CONSTRUCTION, AND COMISS
V
1
Apakah perusahaan Anda memiliki prosedur kerja sesuai Daftar dan salinan prosedur kerja sesuai dengan lingkup pekerjaan? dengan lingkup pekerjaan Does your company have working procedure related to the scope of work?
Apakah perusahaan Anda memiliki rencana program 2 K3LL untuk pelaksanaan proyek?
3
4
List and copy of working procedure related to the scope of work
Salinan rencana program K3LL
Does your company have HSE plan for project execution?
Copy of HSE plan
Apakah perusahaan Anda memiliki prosedur identifikasi bahaya dan penilaian risiko?
Salinan prosedur identifikasi bahaya dan penilaian risiko (JSA, RA)
Does your company have hazard identification and risk assesment procedure?
Copy of hazard identification and risk assesment procedure (JSA, RA)
Apakah perusahaan Anda memiliki contoh JSA dan RA sesuai dengan detail / lingkup pekerjaan?
Contoh JSA dan RA sesuai dengan detail / lingkup pekerjaan
Does your company have an example of JSA and RA related to Example of JSA and RA related to the detail / the detail / scope of work? scope of work
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES Apakah perusahaan Anda memiliki prosedur Izin Kerja 5 Aman? Does your company have Permit to Work procedure?
6
Salinan prosedur Izin Kerja Aman Copy of Permit to Work procedure
Salinan prosedur APD (perawatan, Apakah perusahaan Anda memiliki prosedur tentang APD penyimpanan, dll) dan daftar APD sesuai dan membuat daftar APD sesuai spesifikasi lingkup dengan lingkup pekerjaan (jenis dan pekerjaan? spesifikasi sesuai standar nasional / internasional)
Does your company have PPE procedure and make a list of PPE and specification related to the scope of work?
Bagaimana perusahaan Anda memastikan APD telah diterima oleh karyawan sesuai dengan lingkup 7 pekerjaan?
Copy of PPE procedure (maintenance, storage, etc.) and list of PPE related to the scope of work (type and specification according to national / international standards)
Catatan distribusi dan inventarisasi APD
How does your company ensuring PPE accept properly by worker related to the scope of work?
PPE distribution record and inventory
Apakah perusahaan Anda memiliki program Higiene Industri? (pencahayaan, debu, suhu, ergonomi, dll)
Laporan pengukuran Higiene Industri
Does your company have Industrial Hygiene program? (illumination, dust, temperature, ergonomic, etc.)
Industrial Hygiene measurement report
Apakah perusahaan Anda memiliki prosedur pengendalian tumpahan bahan kimia?
Salinan prosedur pengendalian tumpahan bahan kimia
Does your company have chemical spill handling procedure?
Copy of chemical spill handling procedure
8
9
Apakah perusahaan Anda memiliki prosedur pengelolaan Salinan prosedur pengelolaan limbah limbah? 10
11
Does your company have waste management procedure?
Copy of waste management procedure
Bagaimana cara perusahaan Anda menangani limbah B3? (oli bekas, tumpahan minyak, material B3 kadaluarsa, pelarut, dll)
Manifest limbah B3
How does your company handle hazardous waste? (used oil, oil spill, expired hazardous material, solvent, etc.)
Manifest of hazardous waste
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES NILAI TOTAL / TOTAL SCORE MANAJEMEN PERUBAHAN / MANAGEMENT OF CHANGE VI Apakah perusahaan Anda memiliki prosedur manajemen Salinan prosedur manajemen perubahan perubahan? 1 Does your company have management of change procedure? Copy of management of change procedure
Bagaimana cara perusahaan Anda melakukan manajemen perubahan?
Salinan form manajemen perubahan (contoh: perubahan struktur organisasi perusahaan, perubahan penggunaan peralatan di tempat kerja, dll)
How does your company perform management of change?
Copy of management of change form (e.g. organizational-structural change, equipment change, etc.)
2
NILAI TOTAL / TOTAL SCORE INSPEKSI / INSPECTION VII Apakah perusahaan Anda melakukan inspeksi umum tempat kerja? 1
Does your company carry out the general workplace inspection?
Bukti inspeksi K3LL (min: 2 periode inspeksi)
Evidence of HSE inspection (min: 2 inspection periods)
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES Bagaimana cara perusahaan Anda untuk menindak lanjuti Laporan tindak lanjut hasil temuan temuan inspeksi? 2 How does your company follow up the inspection findings?
Report of follow up inspection finding
Apakah peralatan kerja Anda diinspeksi sebelum dikirim ke lokasi proyek (mobilisasi)?
Bukti hasil inspeksi peralatan
Does your company equipments inspected before sent to project site area (mobilization)?
Evidence of equipment inspection results
3
Apakah perusahaan Anda melakukan inspeksi pada alat Jadwal dan hasil inspeksi alat kerja kerja yang digunakan? 4 Does your company do inspection for working equipments?
Equipment inspection schedule and result
NILAI TOTAL / TOTAL SCORE KOMUNIKASI / COMMUNICATION VIII
1
2
3
Apakah perusahaan Anda melakukan rapat toolbox / safety talk?
Daftar hadir dan materi rapat toolbox / safety talk
Does your company carry out toolbox / safety talk meeting program?
Attendance list and materials of toolbox / safety talk meeting
Apakah perusahaan Anda mengkomunikasikan Job Safety Analysis / Risk Assessment?
Daftar hadir komunikasi JSA / RA
Does your company communicate Job Safety Analysis / Risk Assessment?
Attendance list JSA / RA communication
Apakah perusahaan Anda memiliki sarana komunikasi K3LL lainnya? (HSE news, HSE bulletin, HSE Alert dll)
Contoh HSE news, HSE bulletin, HSE Alert dll
Does your company have other HSE communication tool? (HSE news, HSE bulletin, HSE Alert etc.)
Example of HSE news, HSE bulletin, HSE Alert etc.
NILAI TOTAL / TOTAL SCORE TANGGAP DARURAT / EMERGENCY RESPONSE IX Apakah perusahaan Anda memiliki prosedur emergensi? Salinan prosedur emergensi 1 Does your company have emergency procedure?
Copy of emergency procedure
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES Apakah perusahaan Anda melakukan pelatihan 2 emergensi secara berkala? Does your company do the emergency drill regularly?
Laporan pelatihan emergensi Emergency drill report
NILAI TOTAL / TOTAL SCORE PELAPORAN DAN PENYELIDIKAN KEJADIAN KECELAKAAN DAN PENCEMARAN LINGKUNGAN / X REPORTING AND INVESTIGATION OF INCIDENT AND ENVIRONMENTAL POLLUTION 1
Apakah perusahaan Anda memiliki prosedur pelaporan kecelakaan kerja?
Salinan prosedur pelaporan kecelakaan kerja
Does your company have incident reporting procedure?
Copy of incident reporting procedure
Apakah perusahaan Anda mencatat statistik kecelakaan dalam 3 tahun terakhir? (LTIFR, LTISR, dll)
Statistik kecelakaan tiga tahun terakhir (jika ada, mohon lampirkan contoh laporan investigasi kecelakaan)
Does your company record the accident statistic for last 3 years? (LTIFR, LTISR, etc.)
Accident statistic report for last 3 years (if available, please attach example of accident investigation report)
2
XI
NILAI TOTAL / TOTAL SCORE DOKUMENTASI / DOCUMENTATION Kumpulan daftar dokumen, salinan Bagaimana cara perusahaan Anda mendokumentasikan prosedur pendokumentasian, dan lembar dan memperbaharui program K3LL? revisi 1 How does your company document and renew the HSE program?
NILAI TOTAL / TOTAL SCORE
Master list of HSE document, copy of document control prosedur, and historical sheet
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES XII
EVALUASI / EVALUATION Apakah perusahaan Anda memiliki prosedur evaluasi 1 K3LL?
Salinan prosedur evaluasi K3LL
Does your company have HSE evaluation procedure?
Copy of HSE evaluation procedure
Apakah perusahaan Anda melakukan internal audit K3LL?
Jadwal dan laporan hasil internal audit K3LL
Does your company carry out HSE internal audit?
Schedule and report of HSE internal audit
Apakah perusahaan Anda memiliki sertifikat sistem manajemen K3LL dari pemerintah / badan sertifikasi?
Salinan sertifikat OHSAS 18001: 2007, ISO 14001: 2004, SMK3, penghargaan jam kerja aman, dll
Does your company have HSE management system certification from government / certification agencies?
Copy certificate of OHSAS 18001:2007, ISO 14001: 2004, SMK3, reward for zero accident, etc.)
2
3
NILAI TOTAL / TOTAL SCORE REWARD DAN PUNISHMENT / REWARD AND PUNISHMENT XIII Apakah perusahaan Anda memiliki prosedur tentang Salinan prosedur promosi / reward HSE promosi / reward HSE? 1 How does your company have HSE promotion / reward procedure?
Copy of HSE promotion / reward procedure
Bagaimana perusahaan Anda menerapkan program reward dan punishment HSE?
Salinan penghargaan atau pemberian hadiah kepada pekerja Salinan sangsi disiplin kepada pekerja mengenai pelanggaran K3LL
How does your company implement HSE reward and punishment program?
Copy of reward for worker Copy of punishment for worker regarding HSE violation
2
NILAI TOTAL / TOTAL SCORE NILAI TOTAL KESELURUHAN / TOTAL SCORE OVERALL
Minimal Skor kelulusan Offshore 70 Minimal Skor kelulusan High Risk 60 Minimal Skor kelulusan Low Risk 50
PT………. HAS ED THE QUALIFICATI Prepared by, date…………
CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES
HSE Engineer
YSTEM QUESTIONNAIRE
□ Mesin Pilling / Pilling Machine □ Pompa / Pumps □ Kapal Laut / Vessel □… □…
ti prosedur, pelatihan, dan sertifikasi sesuai
ning, and certification related to each kind of
□ Earth Work & Earth Moving □ Chemical Cleaning □ Electrical □ Cathodic Protection Activity □ Post Trenching □ Weather Forecast Activity □ HVAC Installation □ Steel Structure
YSTEM QUESTIONNAIRE
□ Temporary Facility □ Topography □ Transportation Provider □… □… □…
shall be completted by Company who propose CSMS assessment
Perwakilan Perusahaan, Company Representative,
: :
YSTEM QUESTIONNAIRE NILAI / SCORE BOBOT / WEIGHT
0
2
0
2
0
2
0
2
0
8
0
2
0
2
ANCE
KETERANGAN / REMARK
YSTEM QUESTIONNAIRE 0
2
0
3
0
2
0
2
YSTEM QUESTIONNAIRE
0
2
0
2
0
15
0
4
0
2
0
6
0
2
0
2
0
4
YSTEM QUESTIONNAIRE
N, AND COMISSIONING
0
2
0
4
0
2
2
YSTEM QUESTIONNAIRE
0
2
0
2
0
2
0
2
0
2
0
2
0
2
YSTEM QUESTIONNAIRE 0
24
0
2
0
2
0
4
0
2
YSTEM QUESTIONNAIRE
0
2
0
2
0
2
0
8
0
2
0
2
0
2
0
6
0
3
YSTEM QUESTIONNAIRE
0
3
0
6
0
2
0
2
0
4
0
2
0
2
NGAN /
YSTEM QUESTIONNAIRE
0
3
0
3
0
3
0
9
0
2
0
2
0
4
0
100
UALIFICATION Reviewed by,
YSTEM QUESTIONNAIRE
HSE Senior Engineer
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