W = 10 cm

Form No : FM-SHE-19

OBSERVASI KESELAMATAN KERJA /

SAFETY WORK OBSERVATION

Tanggal & Jam : Nama Orang yang terlibat :

Date & Time Name of People involved

Nama Observer & ID : Jenis & No. Unit yang terlibat :

Name & ID Observer Type & No. Unit involved :

Paraf Observer: Departemen yang bertanggung jawab :

Signature of Observer Responsible Department

Department Observer: Perusahaan yang bertanggung jawab :

Department of Observer Responsible Company
H = 15 cm
Lokasi Bahaya / Hazard Location :
Deskripsi Bahaya / Hazard Description : r Unsafe Act r Unsafe Condition

Tindakan Perbaikan / Action :

Nama & ID yang melakukan perbaikan :

Signature :
Name & ID to take action

Tanggal & Jam Perbaikan : Diverifikasi oleh SHE :

Date & Time of action Verified by SHE
TINGKAT RESIKO / RISK RATING
RENDAH Menyebabkan cedera ringan / May result in First Aid Injury 1

SEDANG Memerlukan bantuan medis atau kerusakan properti tingkat sedang / 2

May result in medical help or moderate level of property damage

Menyebabkan cedera serius atau menyebabkan hari kerja yang hilang

TINGGI atau kerusakan properti berat / May result in serious injury or Lost Time 3
or major level of property damage

SANGAT TINGGI Menyebabkan kematian / May result in fatality 4

-Lembar Asli ke Supervisor yang bertanggung jawab dan setelah perbaikan di lakukan form diserahkan
ke SHE / Original sheet reported to Responsible Supervisor and after actioned shall be given to SHE
-Setelah melaporkan bahaya, kertas copy carbon langsung diserahkan ke SHE / Copy carbon shall be
Immediately given to SHE after report the hazard
 Lampiran / Attachment

Jenis temuan yang Jenis temuan yang

teramati / Type of finding (√) teramati / Type of finding (√)

Risk assesment Industrial hygiene

PPE Housekeeping
Working at height Hazardous & toxic waste
Lifting operation Hazardous & toxic subs.
Working near or above water Ladder, platform, scaffold
Lock out tag out Electrical safety
Cinfined space Smoking violation
Driving safely Guarding
Hot work permit Welding & cutting
drug / alcohol Hand & power tool
Supervisory / JSEA Unsafe act
Emergency system Unsafe condition