Form Izin Kerja K3 [PDF]

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MEIJI FOOD INDONESIA



Nomor



No. Dok No. Revisi Tgl Rilis Hal



SURAT IZIN PEKERJAAN RESIKO TINGGI HIGH RISK WORK PERMISSION



:



Tanggal/Date



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KLASIFIKASI PEKERJAAN/WORK CLASSIFICATION Kerja Panas Hot Work



Kerja Listrik Electrically



Ketinggian Work at height



Galian Excavation



Tanki Tank



Ruang Terbatas Confined Space



Plafon Ceiling



Dibawah Lif Under Lif



INFORMASI PEKERJAAN/WORK INFORMATION Pekerjaan/Work Lokasi Kerja/Work Location Area Department Nama Pemohon/Name of Applicant Nomor Kontak Pemohon/Contact Number of Applicant Nama Pimpinan Area/Name of Area Leaders Nomor Kontak Pimpinan Area/Contact Number of Area Leaders Nama Pengawas/Supervisor Nomor Kontak Pengawas/Contact Number of Supervisor Petugas K3/Safety Officer Nomor Kontak Petugas K3/Contact Number of Safety Officer



: : : : : : : : : : : :



PERLENGKAPAN KERJA/WORK EQUIPMENT ALAT/EQUIPMENT



JML/QTY



MESIN/MACHINE



JML/QTY



MATERIAL



JML/QTY



*Semua perlengkapan kerja diperiksa oleh petugas K3/Every work equipment checked by safety officer



KESELAMATAN KERJA/WORK SAFETY No.



AKTIVITAS/ACTIVITY



POTENSI BAHAYA/POTENTIAL HAZARD



LANGKAH AMAN PEKERJAAN/SAFE WORK STEPS



PERALATAN KESELAMATAN/SAFETY EQUIPMENT Alat Pelindung Diri/Personal Protective Equipment



Perlengkapan Keselamatan & Darurat/Safety Equipment & Emergency



[ ] Helm/Helmet [ ] Kacamata/Glasses [ ] Goggle [ ] Tameng Muka/Face Shield [ ] Kap Las/Welding Cup [ ] Masker Kain/Cloth Mask [ ] Masker Kimia/Checmical Mask [ ] Earplug [ ] Earmuf [ ] Sarung Tangan Katun/Cotton Gloves



[ ] Pemadam Api (APAR, Karung Goni Basah)/ Fire Extinguisher [ ] Barikade (Garis Tanda Bahaya)/Warning Danger Line [ ] Rambu/Tanda Keselamatan/Safety Sign [ ] LOTO (Log Out Take Out) [ ] Radio Telekomunikasi/Telecommunication Device [ ] Jaring/Tali Keselamatan/Safety Rope [ ] Lainnya/Others :



[ ] Sarung Tangan Karet/Rubber Gloves [ ] Sarung Tangan Kulit/Leather Gloves [ ] Sarung Tangan Las/Welding Gloves [ ] Sabuk Keselamatan/Safety Belt [ ] Full Body Harness [ ] Sepatu Keselamatan/Safety Shoes [ ] Sepatu Boots/Boots [ ] Tabung Pernafasan/Respiratory Tube [ ] Apron [ ] Lainnya/Others :



VALIDASI IZIN KERJA/WORK PERMISSION VALIDATION Disiapkan Oleh/Prepared By Pemohon/Applicant Nama/Name : TTD/Signature :



Diperiksa Oleh/Checked By Petugas K3/Safety Officer Nama/Name : TTD/Signature :



Diketahui Oleh/Known By Supervisor Nama/Name : TTD/Signature :



Disetujui Oleh/Approved By Manager Nama/Name : TTD/Signature :