Project Name :

Date :
Name of Candidate :
Position :

HSE PERSONNEL ASSESSMENT

RESULT REMARKS
NO KRITERIA ASSESSMENT
5 6 7 8 9 10
I HSE Management System Ability      
1.1 Hazardous / Chemical Management    
1.2 Knowledge of Handle Compressed Gas        
1.3 Knowledge of Emergency Response
1.4 Knowledge of General Inspection        
1.5 Knowledge of Work Permit        
1.6 1.6.1 Hot Work    
1.7 1.6.2 Excavation Work        
1.8 1.6.3 Confined Space Work        
1.9 1.6.4 Hot Tap work        
1.10 1.6.5 Night Work        
1.11 1.6.6 Radiography Work        
1. 12 Knowledge of Job Safety Analysis        
1.13 Knowledge of Accident Investigation        
1.14 Knowledge on Audit      
1.15 Knowledge of LOTO        
1.16 Knowledge on Environmental Matter
1.17 Knowledge first aid
1.18 Knowledge of PPE
1.19 Knowledge of toxic gas
1.20 Knowledge of scaffolding
1.21 Knowledge of basic fire fighting
1.22 Knowledge of rigging & lifting
   Questioner
  AVERAGE SCORE    on page 5
II Work Experience with Rekayasa Industri        
  2.1 HSE Officer        
  2.1.1 HSE Officer Geothermal        
  2.1.2 HSE Officer Gas        
  2.1.3 HSE Officer Petrochemical or Refinery        
  2.1.4 HSE Officer in Mineral and Agro        
           
  2.2 Chief Safety        
  2.2.1 Chief Safety in Geothermal        
  2.2.2 Chief Safety Gas        
  2.2.3 Chief Safety Petrochemical or Refinery        
  2.2.4 Chief Safety Mineral and Agro        
           
  2.3 HSE Manager        
  2.3.1 HSE Manager Geothermal        
  2.3.2 HSE Manager Gas        
  2.3.3 HSE Manager Petrochemical or Refinery        
  2.3.4 HSE Manager Mineral and Agro        
   
  SCORE  
III Work Experience related to HSE       See note*)
 RESULT REMARKS
NO KRITERIA ASSESSMENT
5 6 7 8 9 10
  3.1 Geothermal      
  3. 2 Oil and Gas exploration      
  3.3 Refinery & Petrochemical      
  3.4 Mineral & Agro      
3.5 Manufacture
3.6 Construction / EPC
   
  SCORE
IV Educational Background   See note *),
  4.1 D3 HSE or Technical NO SCORING based on
  4. 2 S1 OHSE or Technical administration
4.3 S2 OHSE or Technical requirement
V Safety Certificate / Training / Knowledge        Knowledge
5.1 AK 3 Umum / HSE Management System certificate score refer to
  and Knowledge       questionnaire
  5.2 First Aid training certificate and knowledge       No.16, please
  5.3 PPE training certificate and knowledge       see score
5.4 Toxic Gas & Hazardous Material training and category
  knowledge        
 
  5.5 Scaffolding training certificate and knowledge      
 
  5.6 Basic Fire Fighting and knowledge      
 
  5.7 Basic Safety Training        
5.8 Rigging & lifting and knowledge  
 
  AVERAGE SCORE    
VI Ability to Speak English and Indonesia        
  6.1 English        
  6.2 Indonesia        
 
  AVERAGE SCORE    
VII Ability to Operate Computer Software        
  7.1 Microsoft Word        
  7.2 Microsoft Excel        
  7.3 Microsoft Power Point        
  7.4 ………        
  

  AVERAGE SCORE
VIII Leadership      
  8.1 Presentasi Skill      
  8. 2 Simulasi Project      
  8.2.1 Knowledge of How to Coordinate Safety Group      
8.2.2 Knowledge of How to Coordinate with other
 
  dicipline      
 
  8.2.2 Knowledge of How to prepare the plan        
  8.2.3 Knowledge of How to control the plan        
   
  AVERAGE SCORE    

OVERALL AVERAGE SCORE

SCORE = OVERALL AVERAGE SCORE
X 10
   
Customer review based on experience:    
 RESULT REMARKS
NO KRITERIA ASSESSMENT
5 6 7 8 9 10

RECOMMENDATION :
 
 
 
 

*) Note:
Chief Safety : D3 technical / OHS: 8 Years Experience and , S1/S2 : 7 Years Experience related to
HSE
HSE Manager D3 technical / OHS : 9 Years Experience and S1/S2 : 8 Years Experience : related to
HSE
HSE S/I D3 or S1 technical / OHS with exceed 3 years experience related to HSE in EPC
D3 or S1 non technical and non OHS with exceed 7 years experience related to HSE
in EPC
Score Category for Score 0 : Can not answer
Question
Score 5 : Can answer 30-49%
Score 6 : Can answer 50-59 %
Score 7 : Can answer 60-79 %
Score 8 : Can answer 80-89 %
Score 9 : Can answer 90-99 %
Score 10 : Can answer 100 %
Score category for work
experience Score 5 : No experience related HSE
Score 6 : 2 years as HSE supervisor / inspector/ officer
: 3-5 years as HSE Supervisor / officer/ 2 years as HSE
Score 7 coordinator
Score 8 : 7 years as chief HSE/ 2-5 years as HSE Manager
Score 9 : 10 years as HSE Manager
Score 10 : 15 years as HSE Manager

Score category for training Score 5 : No training and score knowledge 5

Score 6 : No training and score knowledge 6-7
Score 7 : Have certificate in house training and knowledge 7 <
Score 8 : Have certificate third party/certification body and score
knowledge 7<
Score 9 : Have certificate advance training from certification body and
score knowledge 8<
Score 10 : Experience as trainer or HSE Specialist

Minimal Score Chief Safety 70 from 100

Minimal Score Project HSE 80 from 100
Manager
Minimal Score HSE S/I 65 from 100

Score By :
Sign :

Name :

QUESTIONER HSE PERSONAL ASSESSMENT

1. Hazardous / Chemical Management Score :
A What needs to be considered to handling hazardous chemical include transportation, storage, and usage ?
Apa yang perlu diperhatikan dalam dalam mengelola bahan kimia berbahaya temasuk pengangkutan,
penyimpanan dan penggunaan?

B Describe MSDS (what is MSDS, function, content’s, and how to manage)?

Deskripsikan MSDS ( apakah MSDS itu, apa fungsinya, isi dan bagaimana mengelolanya)?

 
2. Knowledge of Handle Compressed Gas Score :

Describe how to storage, transport, and usage cylinder compressed gas (example O2, acetylene, argon, LPG,
N2)?
Jelaskan bagaiman penyimpanan, pengangkutan dan penggunaan tabung gas bertekanan ( misalnya O2,
asetylene, argon, LPG, N2)?

3. Knowledge Emergency Response Score:

A
What need to be considered in emergency response?
Apa yang perlu diperhatikan dalam tanggap darurat?
 Describe allocation of emergency response team
Deskripsikan pembagian tim tanggap darurat

 
4. Knowledge of General Inspection Score :

Please explain how to conduct inspection for equipment for example crane and welding machine?
Jelaskan bagaimana melakukan inspeksi peralatan misalnya krane dan mesin las?

5. Knowledge Work Permit Score :

Please explain about work permit, function’s, what the requirement that shall be completed to get work permit
and what job that need work permit?
Jelaskan tentang tentang ijin kerja, fungsi, apa yang harus dilengkapi untuk mendapatkan ijin kerja dan
kriteria pekerjaan apa yang memerlukan ijin kerja.
 
6. Knowledge Hot Work Score :

Describe term of hot, give example, hot work hazard and how to control it?
Deskripsikan definisi pekerjaan panas, contoh pekerjaan panas, bahaya pekerjaan panas dan bagaimana
menanggulanginya?

 
7. Excavation work Score :

Mention of excavation hazard and how to control this hazard?

Sebutkan bahaya pekerjaan penggalian dan bagaimana cara mengendalikan bahaya tersebut?

8. Confined Space work Score :

Describe term of confine space work, hazard and control measures?

Deskripsikan definisi pekerjaan di ruang terbatas , sebutkan bahayanya dan bagaimana mengendalikannya?

 
9. Hot Tap Work Score :
 Describe term of hot tap work and please mention hazard and how to controls this hazard?
Deskripsikan definisi pekerjaan hot tap , sebutkan bahaya beserta penanggulangannya?

 
10. Night Work Score :

Mention hazard of night work and how to control this hazard?

Sebutkan bahaya pekerjaan malam dan bagaimana cara mengendalikan bahaya tersebut?

 
11. Radiography Work Score :
A Describe the radiography work, please mention it hazard and how to control this hazard ?
Jelaskan apakah pekerjaan radiography itu, sebutkan bahayanya dan bagaimana mengendalikan bahaya
tersebut?

B Who is authorized person to perform radiography work?

Siapakah orang yang memiliki otoritas menyelesaikan pekerjaan radiografi?

 
12. Knowledge of Job Safety Analysis Score :

What is JSA who is responsible to establish and give example?

Apakah JSA itu , siapakah yang bertanggung jawab membuat dan berikan contoh JSA?
 
13. Knowledge of Accident Investigation Score :

What is the purpose of accident investigation, who will conduct, and please describe how to conduct accident
investigation?
Apakah tujuan dilakukannya investigasi kecelakaan, siapa yang berhak melakukan dan bagaimana cara
melakukan investigasi?

 
14. Knowledge on Audit Score :

Describe what is Audit, purpose and who will conduct audit, how to handle audit result?
Deskripsikan apakah audit, tujuan dan siapa yang melakukan audit, dan bagaimana menangani hasil audit?

 
15. Knowledge of LOTO Score :

Describe term and function of LOTO, what kind condition of LOTO should be apply, please explain how to
use LOTO?
Deskripsikan definisi dan fungsi dari LOTO, pada kondisi apa harus menggunakan LOTO dan bagaimana
penggunaannya?
16. Knowledge Environmental Matter Score :

A Explain the definition of hazardous waste based on PP No. 101 Tahun 2014
Terangkan definisi limbah B3 menurut PP No. 101 Tahun 2014?

B What is the meaning of hazardous waste manifest

Apakah yang dimaksud dengan manifest limbah B3?

C Please mention min 5 hazardous material and handling!

Sebutkan minimum 5 bahan B3 beserta penangannnya!

D Please mention minimum 2 ways to controlling sediment!

Sebutkan minimum 2 cara pengontrolan sedimen!
E How often we have to conduct environmental monitoring?
Seberapa sering kita harus melakukan pemantauan lingkungan?

F Please mention minimum 3 materials that must be monitored to define ambient air quality!
Sebutkan minimal 3 zat yang harus dimonitor untuk kualiatas udara ambien!

G Monitoring of waste water quality could be conducted by dot and line sampling method, please explain these
methods?
Pemantauan kualitas air limbah dapat dilakukan dengan cara pengambilan sampel titik dan garis jelaskan
kedua metode tersebut!

H Please mention kind of quality standard to be used to conduct waste water monitoring? Please describe why
we have to use this quality standard!
Baku mutu apa sajakah yang digunakan untukmelakukan pemantauan air limbah, sebutkan dan jelaskan
mengapa menggunakan baku mutu tersebut!
I Which regulation that used to determine a quality standard (local regulation or government regulation)
Peraturan yang mana yang dipakai untuk penetapan baku mutu (peraturan pemerintah daerah atau
peraturan pemerintah pusat)!

J Could you explain storage requirement of hazardous material, give detail!

Jelaskan syarat-syarat penyimpanan bahan B3!

17. First Aid Score:

Describe the principle and step of first aid?
jelaskan prinsip dan langkah-langkah P3K?
18. Knowledge of PPE Score:
A Please mention PPE as per activities?
Sebutkan APD berdasarkan pekerjaan?

B Describe how to inspect PPE ( shoes, helmet, full body harness, SCBA)
Jelaskan bagaimana melakukan inspeksi terhadap APD ( sepatu, helm, full body harness dan SCBA)

19. Toxic Gas Score:

What is TLV (Threshold Limit Value), STEL ( short-term exposure limit), please mention TLV min 3 toxic
gas?
Apakah yang dimaksud dengan nilai ambang batas dan nilai batas paparan singkat, sebutkan nilai ambang
batas untuk minimal 3 jenis gas beracun?
20. Scaffolding Score:

What the purpose built scaffolding , give sketch and mention the component of frame scaffolding and pipe
tube, what is to be consider to determine scaffold is safe for used?
Apakah tujuan dibangunnya scaffolding, gambarkan scaffolding frame dan pipa dan sebutkan komponennya,
dan apa saja yang perlu diperhatikan dalam menentukan bahwa scaffolding aman digunakan?

21. Basic Fire Fighting Score:

Please mention equipment for fire fighting and fire extinguisher type based on their purposes?
Sebutkan perlengkapan yang dipakai untuk pemadaman kebakaran dan sebutkan jenis APAR menurut
kegunaannya.

22. Rigging & lifting Score:

Please describe about rigging plan, Mention factor that be considered to determine safe work load
?
Jelaskan tentang riging plan dan sebutkan factor yang diperhatikan dalam menentukan beban angkat yang
aman ?