HSE DAILY REPORT

PROYEK:Relokasi/Proteksi LOKASI : TANGGAL:

Jaringan utilitas yang terkena
pembangunan jalan tol ciawi-
sukabumi seksi 1

I. CONTRACTOR ACTIVITIES
Equipment/Tool
No Location Activities Supervisor Worker
Kind Quantity
1 Cigombong Cleaning area 1 12 Cangkul 6
Blencong 6
Arit 2

II. HSE ACTIVITIES

No Activities Today Before Total Remark
1 Orientation/Induction
2 Toolbox Meeting
3 Job Safety Analysis
4 Permit To Work
5 Risk Containment Audit
6 HSE Meeting
7 Environmental monitoring
8 Health Check
9 Inspection
10 Incident / Investigation
11 Safety Promotion
12 Emergency Drill
13 Training
14 Audit
15 Other …………………….
III. PERSONAL PROTECTIVE EQUIPMENT
DIBERIKAN KE PEKERJA
No Kind of PPE Remark
Today Record
1 Safety Shoes 13
2 Safety Helmet 13
3 Safety Glases 13
4 Gloves
5 Ear plug/Ear muff
6
7
8
IV. PERFORMANCE REPORT
4.1 Incident Report
No Type of Incident Today Before Total Remark
1 Near Miss

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 HSE DAILY REPORT
PROYEK:Relokasi/Proteksi LOKASI : Cigombong Bogor TANGGAL: 28 Juli 2016 (Kamis)
Jaringan utilitas yang terkena
pembangunan jalan tol ciawi-
sukabumi seksi 1

2 First Aid Case

3 Medical Treatment
4 Lost Time Injurie
5 Fatality
6 Fire Accident
7 Traffic Accidennt
8 Propertiy Damage
9 Environmental Damage
4.2 Manhour& Safe Manhour
Today Before Total
No Company Remark
Worker Safe Manhour Safe Manhour Safe Manhour
1 parba
2 Parba (overtime)
3 Parba (overtime)
3

Grand Total
4.3 Safe Vehicle Distance
No Company Today Before Total Remark
1 parba
2
3
Grand Total
V. WEATHER RECORD
Time Sunny Cloudy Rainy Time Sunny Cloudy Rainy
07.00 – 08.00 13.00 – 14.00
08.00 – 09.00 14.00 – 15.00
09.00 – 10.00 15.00 – 16.00
10.00 – 11.00 16.00 – 17.00
11.00 – 12.00 17.00 – 18.00
12.00 – 13.00 18.00 – 19.00
PGASSOL PMO IT SUMTENG-TSJ
NAMA

TANDA TANGAN

TANGGAL

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