No.

: DR/HSE/XYZ/002
Revisi : 00
DAILY SAFETY REPORT Tgl. Efektif :-
Halaman : 1 of 11)

DATE :
1 WEATHER CONDITION

6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00

Note:

2 HSE PERFORMANCE STATISTIC

MANHOURS PREVIOUS TODAY CUMMULATIVE LOST TIME ACCIDENT

TOTAL MANHOURS

HSE INPUT PREV. TODAY CUMM. TARGET REMARKS

Hazard Observation
HSE Inspection & Audit
Safety Meeting
HSE Orientation / Induction
Management Visit
Safety Traning
ERP Drill
Anomally Record
Job Safety Analysis (JSA)

HSE OUTPUT PREV. TODAY CUMM. TARGET REMARKS

First Aid Injury (FAI)
Lose Time Injury ( LTI )
Medical Treatment Injury (MTI)
Fire Incident (FI)
Property Damage
Environment Incident
Total Recordable Injury

NO. ISSUES ACTION PLAN TARGET DATE ACTION BY

1
2
4
5

3 WORK PERMIT

NO. LOCATION PTW No. TYPE SUPERVISO DESCRIPTION OF WORK ISSUE DATE VALID DATE
R
1
2
3
4
5
6

4 MAN POWER

DESCRIPTION ETI Security

SHIFT I
SHIFT II
TOTAL SHIFT I
TOTAL SHIFT II
TOTAL MAN POWER
Plan Additional MP

5 SAFETY HIGHLIGHT (ACTIVITY)

Reported by, Acknowledged by,

HSE Koordinator