PRIMA NIRBHAYA MSE 2.

08
Form
FIRST AID BOX INSPECTION AND REGISTER FORM
(Lampiran II - Peraturan Menteri Tenaga Kerja dan Transmigrasi Republik Indonesia Nomor: PER-15/MEN/VIII/2008)
Step 1 Check Quantity of content if seal is broken ( Periksa jumlah isi jika segel rusak )
Step 2 Check exspiry date of drug ( Periksa masa berlaku obat )
Step 3 Order if any quantity of content is less than minimum requarement ( Order jika obat yang di pakai berkurang )

NOTE: Standard R = Right ; Substandard W = Wrong

No. Description Quantity JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Comments

S ubs tandard

S ubs tandard

S ubs tandard

S ubs tandard

S ubs tandard

S ubs tandard

S ubs tandard

S ubs tandard

S ubs tandard

S ubs tandard

S ubs tandard

S ubs tandard
S tandard

S tandard

S tandard

S tandard

S tandard

S tandard

S tandard

S tandard

S tandard

S tandard

S tandard

S tandard
Ty pe C
Ty pe A

Ty pe B
1 Sterile gauze / Kasa steril terbungkus 20 40 40
2 Bandage - 5 cm / Perban - Lebar 5 cm 2 4 6
3 Bandage - 10 cm / Perban - Lebar 10 cm 2 4 6
4 Plaster - 1,25 cm / Plester - Lebar 1,25 cm 2 4 6
5 Instant Plaster / Plester cepat 10 15 20
6 Cotton wool - 25 gram / Kapas - 25 gram 1 2 3
7 Triangular Bandage / Kain segitiga - Mittela 2 4 6
8 Scissors / Gunting 1 1 1
9 Pin / Peniti 12 12 12
10 Gloves (pairs) / Sarung tangan sekali pakai (pasangan) 2 3 4
11 Mask / Masker 2 4 6
12 Pincers / Pinset 1 1 1
13 Flash light / Lampu senter 1 1 1
14 Glass for eye washing / Gelas untuk cuci mata 1 1 1
15 Plastic bag / Kantong plastik bersih 1 2 3
16 Aquades - 100 ml lar. Saline 1 1 1
17 Povidon Iodin 60 ml 1 1 1
18 Alcohol 70% 1 1 1
19 Hand book of first aid at workplace / Buku panduan P3K di tempat kerja1 1 1
20 Note book / Buku catatan 1 1 1
21 List of box content / Daftar isi kotak 1 1 1

Badge No:
Sign / tanda tangan: Note / Keterangan:
Type A: Untuk mencakup max 25 org
Date / tgl:
Type B: Untuk mencakup max 50 org
Box sealed / kotak terkunci: Yes
Type C: Untuk mencakup max 100 org
No

Document Title Approved By Effective Date

Uncontrolled Document
First Aid Box Inspection And Register Form / When Printed or Out of HSE Info
GM HSES 16 Nov 2015
Formulir Inspeksi dan Register Kotak P3K
Doc. Registration No. Version Next Review Due
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HSE_KPC_KPC_MSE2.08_DOC_FRMb_001 3.1 16 Nov 2020