Scribd
Upload
229 views16 pages

FRM-HSE-00-5,6,7,8,9,10,11,12,13-Check List HSE

The document contains several safety checklist templates for inspecting items like full body harnesses, fire extinguishers, oxygen and acetylene tanks, and the results of safety patrols and environmental checks. It also includes templates for documenting safety violations, inspection schedules, weekly HSE reports, and daily activity reports for a construction or facility management project. The templates are intended to help standardize safety inspections and record-keeping for the property management company PT. Cushman & Wakefield Indonesia.

Uploaded by

Adrianus Pramudhita
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
229 views16 pages

FRM-HSE-00-5,6,7,8,9,10,11,12,13-Check List HSE

The document contains several safety checklist templates for inspecting items like full body harnesses, fire extinguishers, oxygen and acetylene tanks, and the results of safety patrols and environmental checks. It also includes templates for documenting safety violations, inspection schedules, weekly HSE reports, and daily activity reports for a construction or facility management project. The templates are intended to help standardize safety inspections and record-keeping for the property management company PT. Cushman & Wakefield Indonesia.

Uploaded by

Adrianus Pramudhita
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
You are on page 1/ 16

No.

Dokumen : 112-FRM/HSE-00-5
Revisi : --
Tanggal : 28 September 2012

SAFETY CHECK LIST FULL BODY HARNESS

TANGGAL :

LOKASI :

NO URAIAN KONDISI STATUS KETERANGAN

1 TALI
2 HUCK
3 BODY
4 PAD LOCK

TOTAL

Inspected By, Approved By

______________________ ______________________
Pengelola Properti: PT. Cushman & Wakefield Indonesia
No. Dokumen : 112-FRM/HSE-00-6
Revisi : --
Tanggal : 28 September 2012

FIRE EXTINGUISHER DISTRIBUTION


( BUILDING )

TOTAL
NO AREA DETAIL SPECIFICATION REMARKS
FIRE EXTINGUISHER

Reported by: Acknowledged by:

________________ ________________
Safety Supervisor General Manager
Pengelola Properti: PT. Cushman & Wakefield Indonesia
No. Dokumen : 112-FRM/HSE-00-7
Revisi : --
Tanggal : 28 September 2012

LIST OF OXYGEN & ACETYLENE INSPECTED


DATE NOMBRE PRESS..
NO CONDITION LOCATION REMARK
INSPECT OXYGEN ACETYLENE IN CHARGE
Pengelola Properti: PT. Cushman & Wakefield Indonesia
No. Dokumen : 112-FRM/HSE-00-8
Revisi : --
Tanggal : 28 September 2012

SAFETY PATROL COMMENT

Date :
ACTION TAKEN COMPLETED
NO ITEMS BY LOCATION DATE

Safety Representative Signature


1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
Pengelola Properti: PT. Cushman & Wakefield Indonesia
No. Dokumen : 112-FRM/HSE-00-9
Revisi : --
Tanggal : 28 September 2012

ENVIRONMENTAL CHECK LIST


Date :

No Item Location Observation / Comment Remarks


Pengel;ola Properti: PT. Cushman & Wakefield Indonesia
No. Dokumen : 112-FRM/HSE-00-10
Revisi : --
Tanggal : 28 September 2012

SURAT PELANGGARAN SAFETY

No.:
Surat pelanggaran safety diberikan kepada :

Nama :

Kontraktor / Lantai :

Tenant :

Karena yang bersangkutan melakukan pelanggaran terhadap standard dan/atau peraturan safety

Jenis pelanggaran :

Hari dan Tanggal :

Jam :

Lokasi :

Selanjutnya pemberian Sanksi terhadap pelanggaran safety ini akan dibahas lebih lanjut pada meeting koordinasi

Dilaporkan Penanggung Jawab Mengetahui

Safety Coordinator Kontraktor General Manager

Pengelola Properti: PT. Cushman & Wakefield Indonesia


No. Dokumen : 112-FRM/HSE-00-11
Revisi : --
Tanggal : 28 September 2012

JADWAL INSPEKSI

JENIS INSPEKSI JADWAL INSPEKSI PIC KETERANGAN


DAILY

Pengelola Properti: PT. Cushman & Wakefield Indonesia


No. Dokumen : 112-FRM/HSE-00-12
Revisi : --
Tanggal : 28 September 2012

HSE WEEKLY REPORT

Period :
No. Reported Data This Week Remark

1 Avarage no of employees
2 Man-hours worked
3 First aid cases only
4 Medical cases only
5 Restricted duty cases
* Reidicted days
6 Lost work days cases
* Incident rate
7 Lost work days cases
* Severity rate
8 Fatalities
9 Record able cases
10 Number of near miss
11 Number of fires
12 Equipment accident
13 Automobile accident
14 Environmental incident
15 Government

Reported by, Acknowleged by,

HSE Supervisor General Manager


Pengelelo Properti:
PT. Cushman & Wakefield Indonesia
No. Dokumen : 112-FRM/HSE-00-13
Revisi : --
Tanggal : 28 September 2012

DAILY ACTIVITY REPORT


Project / No Job : SIGNATURE SIGNATURE
Tanggal date :
Dicatat oleh record by : SAFETY SUPERVISOR OPERATION MANAGER

I. SITE SAFETY ACTIVITY

II. SITE SAFETY INSPECTOR


NO UNSAFE ACT / CONDITION LOCATION ACTION TAKEN

III. ACCIDENT / INCIDENT OCCURRED

IV. ACTIVITY PLANT TOMORROW

V. NOTE
Pengelola Properti: PT. Cushman & Wakefield Indonesia

You might also like