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Environment, Health, Fire and Safety (EHFS) Assessment

Project :

Contractor/ Subcontractor's Name :

Section I EHFS Policy and Leadership

1. Does your company have an EHFS policy document ?

Apakah perusahaan anda mempunyai Kebijakan Keselamatan Kerja, Kesehatan dan
Lingkungan?

Yes No

If yes, please attach / Jika Ya, silahkan untuk dilampirkan.

2. Who has overall and final responsibility for EHFS in your organization?
Siapa yang bertanggung jawab secara keseluruhan (otoritas) terhadap Keselamatan Kerja,
Kesehatan dan Lingkungan diperusahaan anda?

Name: Job Title:

3. Who is the most senior person in the organization responsible for this policy being carried out at
the premises and on site where his employees are working?
Siapa senior staff di perusahaan anda yang bertanggung jawab dalam implementasi kebijakan
ini di project tempat anda bekerja?

Name: Job Title:

Section II General Organization -Management Structure / Organization

4. Please attach a current organisation chart showing reporting relationships from your Chief
Executive Officer to lowest line manager / Silahkan lampirkan struktur organisasi perusahaan
anda mulai dari Direktur Utama sampai ke Manager
Organization chart attached?

Yes No

5. Does a full time EHFS Department exist in your organization?

Apakah Departement K3 tersedia di perusahaan anda?

Yes No

CONFIDENTIAL

This document is solely for the use of Sinar Mas Group personnel. No part of it may be circulated, quoted, or reproduced for distribution outside the senior management of
Sinar Mas Group without prior written approval from an authorized officer.
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Environment, Health, Fire and Safety (EHFS) Assessment

6. If answer to 5 above is yes, do you have job descriptions for the person(s) employed in your
EHFS Department?
Jika jawaban no 5 Ya, Apakah perusahaan anda mempunyai job description terhadap karyawan
di Departement K3.

Yes No

If yes, Please give detail the position and responsibilities

Jika Ya, silahkan lampirkan detail dari posisi masing-masing karyawan dan responsibilitinya.

7. If the answer to item 5 above is no, who is responsible for providing safety advice and
monitoring the implementation of EHFS Management System at your work sites and what is
their qualification?
Jika jawaban no.5 Tidak ada, siapa yang bertanggung jawab dalam memberikan arahan K3 dan
melakukan monitoring terhadap implementasi K3 management system ditempat perusahaan
anda bekerja dan apa kualifikasi orang tersebut?

Person Responsible :

Qualification :

Section III Organizing for EHFS Planning

8. Do you produce an EHFS Plan for each Project?

Apakah anda menyiapkan rencana pelaksanaan pencegahan pencemaran, kecelakaan kerja
dan kebakaran (EHFS) di project ini?

Yes No

9. If answer to Question 8 above was no, briefly describe how you ensure that the required EHFS
Systems are communicated and implemented on time.
Jika jawaban anda Tidak, Jelaskan bagaimana anda memastikan pelaksanaan pencegahan
pencemaran, kecelakaan kerja dan kebakaran (EHFS) yang disyaratkan dapat terkomunikasi
dan dilaksanakan dengan baik.

Section IV Organizing for EHFS Training

10. Do you have a EHFS Training Matrix for your employees?

Apakah perusahaan anda mempunyai rencana training LK3 untuk karyawan anda?

Yes No

11. If the answer to Question 10 above was no, briefly describe how you identify and implement
EHFS Training for your staff.
Jika jawaban no 10 Tidak ada, Jelaskan bagaimana anda mengidentifikasi dan
mengimplementasi kebutuhan trainining LK3 untuk karyawan anda.

CONFIDENTIAL

This document is solely for the use of Sinar Mas Group personnel. No part of it may be circulated, quoted, or reproduced for distribution outside the senior management of
Sinar Mas Group without prior written approval from an authorized officer.
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Environment, Health, Fire and Safety (EHFS) Assessment

12. Do you have a formal training program(s) for Supervisors their responsibilities in EHFS
Management as Supervisors?
Apakah perusahaan anda mempunyai program training untuk safety supervisor ?

Yes No

13. If the answer to item 12 above is yes, briefly describe this program and who conducts this
training.
Jika jawaban no 12 Ya, Jelaskan bagaimana program ini berjalan dan siapa yang melakukan
training tersebut.

14. Do you have a formal EHFS Orientation Programs for new employees?
Apakah perusahaan anda mempunyai Program Safety Orientation untuk karyawan baru?

Yes No

Section V Organizing for EHFS Procedures

15. Does your Company have written EHFS procedures?

Apakah perusahaan anda mempunyai procedure Lingkungan & K3 (LK3) ?

Yes No

16. If answer to Question 15 was yes, please attach HSE Procedure that you have.
Jika jawaban no.15 Ya, Silahkan lampirkan procedure LK3.

Section VI Managing EHFS -Accident Performance Measurement

17. Do you measure environmental performance?

Apakah perusahaan anda mengukur performance lingkungan?

Yes No

If yes, state what and how

Jika Ya, Jelaskan apa yang di ukur dan Bagaimana

What?

How?

18. Do you keep Accident / Incident Statistics for your Employees?

Apakah perusahaan anda menyimpan statistic kecelakaan terhadap karyawan anda?

Yes No

19. If the answer to item 18 above is yes, briefly describe the Accident/Incident Statistics you keep
and the analysis you perform on these
Jika jawaban no 18 Ya, jelaskan jenis kecelakaan yang anda muat di statistic tersebut.
CONFIDENTIAL

This document is solely for the use of Sinar Mas Group personnel. No part of it may be circulated, quoted, or reproduced for distribution outside the senior management of
Sinar Mas Group without prior written approval from an authorized officer.
 No Form : OP AA 6 0117-00

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Environment, Health, Fire and Safety (EHFS) Assessment

20. Do you keep Accident/Incident Statistics on your Subcontractors?

Apakah perusahaan anda mempunyai statistic kecelakaan terhadap subcontractor anda?

Yes No

Section VII Managing EHFS -Monitoring and Improvement

21. Do your Senior Management conduct an EHFS Audit and Inspection process at the work site?
Apakah senior management anda melakukan audit LK3 dan melakukan inspeksi
terhadap tempat anda melaksanakan pekerjaan?

Yes No

Section VIII Current EHFS Statistical Information

22. Please provide the following information:

(A) Please provide your statistical EHFS Performance for 3 last years:
Lampirkan statistic LK3 untuk 3 tahun terakhir.

Section IX Personnel Protective Equipment

23. Do you provide appropriate personal protective equipment (PPE) for your employees? Please
provide a listing of the PPE for the scope of this work ?
Apakah perusahaan anda menyiapkan alat pelindung diri untuk karyawan perusahaan anda?
Silahkan list alat pelindung diri yang akan anda siapkan untuk pekerjaan ini?

24. Do you have a program to ensure that PPE is impacted and maintained?
Apakah perusahaan anda mempunyai program pemeliharaan alat pelindung diri?

Section X Rigging and Heavy Equipment

25. Does your company have a lifting equipment (cranes, forklift, truck crane, trailer etc.)?
Apakah perusahaan anda memiliki alat angkat angkut (Crane, forklift, truck crane, trailer dll) ?

26. Do you use heavy equipment always comes with a certified operator and equipment that have
passed the test of inspection of the authorities?
Apakah alat berat yang anda gunakan selalu dilengkapi dengan operator yang bersertifikat
serta alat yang telah lulus uji pemeriksaan dari pejabat yang berwenang?

27. Do you always use the planned lifting when lifting material using lifting equipment (cranes,
Electrical Winch, Overhead Crane etc.) … give examples of rigging plan which company you
use
Apakah anda selalu menggunakan metode pengangkatan yang terencana pada saat
mengangkat material dengan menggunakan alat angkat angkut (Crane, Electrical Winch,
Overhead Crane dll) … beri contoh rigging plan yang perusahaan anda gunakan

CONFIDENTIAL

This document is solely for the use of Sinar Mas Group personnel. No part of it may be circulated, quoted, or reproduced for distribution outside the senior management of
Sinar Mas Group without prior written approval from an authorized officer.
 No Form : OP AA 6 0117-00

Revisi : 00

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Environment, Health, Fire and Safety (EHFS) Assessment

Section XI Scaffolding

28. Does your company use scaffolding to help the work?

Apakah perusahaan anda menggunakan scaffolding untuk membantu pekerjaan ?

29. Is there a supervisor who is responsible for scaffolding work?

Apakah ada supervisor yang bertanggung jawab untuk pekerjaan scaffolding?

Section XII Hazards and Effect Environmental Management

30. Please provide the number of accident resulting in environmental damage or fatality injury in the
amount greater than $ 50,000 for the last 24 months. Attach copies of any goverrnent reports
submitted
Lampirkan kejadian yang menyebabkan pencemaran lingkungan dan kecelakaan kerja fatal
dengan jumlah kerugian lebih dari Rp. 500.000.000 untuk dua tahun terakhir.

31. Who is the person in charge for coordinating environment and safety matter and what is he/she
experience?
Siapa yang bertanggung jawab dalam menghandle untuk melakukan perlindungan lingkungan
diperusahaan anda dan apa pengalaman orang tersebut?

Name: Job Title:

Section XIII Drugs and Alcohol

32. Do you have a drugs and alcohol policy in your organization? If yes please attach.
If No, how do you ensure that your employees do not use drugs and alcohol during project.
Apakah perusahaan anda mempunyai kebijakan pelarangan menggunakan obat dan minuman
terlarang? Jika Ya silahkan lampirkan. Jika Tidak, bagaimana perusahaan anda memastikan
karyawan anda tidak menggunakan obat dan minuman terlarang selama project berjalan.

Section XIV Safety Achievement or Awards

33. Please provide any significant achievements or awards?

Lampirkan penghargaan safety yang pernah didapat.jika ada.

I understand, follow all the requirement and all the answer above is correctly and honest,
Saya mengerti, mengikuti semua persyaratan dan menjawab semua pertanyaan diatas dengan jujur
dan benar.

Signs,

( )
Tittle: Director / Direktur
Date:

CONFIDENTIAL

This document is solely for the use of Sinar Mas Group personnel. No part of it may be circulated, quoted, or reproduced for distribution outside the senior management of
Sinar Mas Group without prior written approval from an authorized officer.