EMERGENCY RESPONSE PLAN (ERP) – EVALUATION FORM

Lokasi ERP Simulasi : Tanggal Dan Waktu : ERP Koordinator :

(Area ERP Simulation) (Date And Time) (ERP Coordinator)

Nama Korban Kerusakan Bangunan : ……………………… Potensi Kerusakan Lain : …………………….

( Name of injured) (Property Damage) ………………………. (Other or Potential Loss) ………………………..
…………………………..
Perkiraan Kerugian : ..………………………. Tipe / (Type) : …………………………
(Cost Estimated) ..……………………… Kerugian / (Cost ) : ………………………………
Waktu Pengendalian Bencana
(Response Time To Handle Incident)
1. Fire Brigade Mengambil Alih Pemadaman : Hour Minutes 4. Team Pemadam Kebakaran : Hour Minutes
(Fire Brigade Come To Handle) (Fire Fighting Extinguish The Fire)
2. Paramedis / Ambulance : Hour Minutes 5. Team P3K : Hour Minutes
(Paramedics / Ambulance) (First Aids team)
3. Pengungsian Seluruh Karyawan : Hour Minutes 6. Total Waktu Pengendalian : Hour Minutes
(Evacuation Of All Employee) (Total Time To Control Incident)

Kronologis Kejadian Bencana Dan Tindakan Pengendalian / (Describe How The Incident Occurred & Emergency Action)
………………………………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………….
Tindakan Perbaikan Untuk Mencegah Terulangnya / (Recommendation for prevention of accident again)
…………………………………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………………………………..
Perbaikan Peralatan Gawat Darurat Pelatihan Yang Diperlukan Untuk Kedaan Gawat Darurat
(Improvement For Emergency Equipment) (Training To Be Needed For Emergency Response Plan)
OK NOK Keterangan / (Note) OK NOK Keterangan /(Note)
1. Alat Deteksi Kebakaran Dan Alarm 1. Pelatihan Pemadam Kebakaran
(Fire Detection And Alarm System) (Fire Extinguisher Drill)
2. Alat Pemadam Api Ringan 2. Pelatihan P3K
(Portable Fire Extinguisher) (First Aids Training)
3. Alat Pemadam Kebakaran 3. Pelatihan Alat Pelindung Diri
(Hose Reel, Hydrant) (Personal Protective Equipment)
4. Fasilitas Evakuasi Kebakaran 4. Pelatihan Gawat Darurat
(Route, Exit Door, Sign) (Emergency Drill)
5. Alat Komunikasi 5. Pelatihan Lain Yang Diperlukan …………………………………..
(Communication Equipment) (Others Training Program) ……………………………………….
6. Lampu Darurat
(Emergency Lighting)
7. Peralatan P3K
(First Aids Equipment)
8. Peralatan Lain / (Others Equipment)