A

Department:

Location:

Last Review Date:

1. Hazard Identification

SN Task Hazards

1 Pekerjaan Galian Tanah Terjatuh

Termasuk Buang Drainase Mata Terhambar Debu
Type 0.9m Infeksi Saluran Pernapasan
Excavator Terguling

Conducted by: (Name, designation)

Signature:
Date:
 Activity or Experiment-Based Risk Assessment Form

1. Hazard Identification

Existing Risk Control

Possible Consequences A B C D
(if any)
mungkin terjadi
mungkin terjadi
kecil kemungkinan
kecil kemungkinan
ent Form
Name of
Experiment/Activity:
Name of Person in-
Name of PI:
charge:
Next Review Date:

2. Risk Evaluation & Control

Additional / New Risk

E 1 2 3 4 5 Action By
Control

Pekerja
Pekerja
Pekerja
Pekerja

Approved by: (Name,

designation)
Signature:
Date:
Deadline