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PT xxxx yyyyyy zzzzzzzz FORM PENILAIAN RESIKO RISK ASSESSMENT Working Unit Last Review Date Next Review Date Revision Status



: : : :



EHS Secretariat



Date :



Work Station/Process



Description of Activity*



Legal Aspect (Y/N)**



Hazard



Division Head



Date :



2. Risk Evaluation ID No.***



Possible accident / ill health



: EHS/005-FM-001 : 02



Application Date



: 01/06/10



Page 1 of 1



1. Hazard Identification No.



No. Revision



Person-at-risk



Existing Risk Control



Seve Likelih Risk rity ood Rating (S) (L) (SxL)



* : Please add remarks in the activity with (R) for routine, (NR) for non-routine, and (E) for emergency situation ** : If "Y", please add remarks with the number of legal, refer to OHS identification and evaluation of compliance (PLJ/EHS/006-FM-001) *** : Fill with working area code and number of hazard. Working area code for ID number refer to Table II. Process Owner Code System in SOP Control of Document page 11 Example : for IPA1, ID number will be 01-1, 01-02, 01-3, etc.



Department Head



Date :



H&S Representative



Date :



3. Risk Control Additional Risk Control



Residual Risk Seve Likeli Risk rity hood Rating (S) (L) (SxL)