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NAWAKARA GROUP NPN-F-OPR-02.

1
REVISION 01

SITE VISIT FORM Register No.


FORM KUNJUNGAN SITE No. Register

PROJECT'S NAME LOCATION / POST


Nama Proyek Lokasi / Pos

SUPERVISOR'S NAME DATE TIME


Nama Supervisor Tanggal Jam
ITEMS TO BE CHECK - YANG HARUS DIPERIKSA

1. SECURITY GUARD - ANGGOTA SATPAM


Please mark √ if exists (Tandai √ jika ada)

UNIFORM AND ACCESSORIES


PPE (APD)
(SERAGAM DAN ASESORISNYA )

(Ikat
Pinggang)
T. Shirt
(Kaos Dalam)
NO NAME (NAMA) BAGDE NO (NO. BADGE)

Google
(Kacamata)
Respirator
Uniform

(Masker)
(Seragam)

T Baton
(Tongkat)
Handcuff
(Borgol)

Hard Hat
(Helm)
Shoes
(Sepatu)

Vest
Badge

(Rompi)
(Badge)
Hat
(Topi)

Belt
1

10

2. PERFORMANCE AND APPEARANCE - KINERJA DAN PENAMPILAN

Tidiness Readiness Understanding Time Keeping


Kerapihan Kesiagaan Pengetahuan Ketepatan waktu COMMENT
NO OFFICER'S NAME NAMA SATPAM
KETERANGAN
3 2 1 3 2 1 3 2 1 3 2 1

10

NOTE
KETERANGAN

3 Above Performance - Di atas kinerja rata-rata


2 Average - Rata-rata
1 Below Performance - Di bawah kinerja rata-rata
3. POST AND EQUIPMENTS - POS DAN PERLENGKAPANNYA
Please mark √ if exists (Tandai √ jika ada)

QTY CONDITION - KONDISI COMMENT


JUMLAH GOOD BAD KETERANGAN
DAILY OCCURRENCE BOOK
1
Buku Jurnal Harian
RADIO COMMUNICATION
2
Radio Komunikasi
FLASH LIGHT
3
Lampu Senter
WATER VESSEL
4
Tempat Air Minum
GUARD TOURS SYSTEM
5
Sistem Guard Tour
POST INSTRUCTION
6
Instrucksi Pos
ELECTRIC SHOCK BATTON
7
Tongkat Listrik
FIRST AID BOX
8
Kotak P3K
POST
9
Pos
HYGIENE APPLIANCES
10
Alat-alat kebersihan
OTHER
11
Lainnya

4. OTHER SUB STANDARD CONDITION - KONDISI DI BAWAH STANDAR LAINNYA

5. CORRECTIVE ACTION - TINDAKAN KOREKSI

CHECKED BY PROJECT MANAGER DATE / TIME


DIPERIKSA OLEH MANAGER PROYEK TANGGAL / JAM

MANAGER'S NAME & SIGN - NAMA & TTD MANAGER

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