Risk Identification, Assessment and Control Measure Form

Company: PT. TARGET TEGUH PERKASA MANDIRI Conducted by: Aksan Damiri (HSE TTPM)
(Name, designation)
Process / Location: HSBC Cab. Medan Center Point Date: (from... to ...)

Approved by:
(Name, designation)
Date: Review Date:

Hazard Identification Risk Analysis Risk Control

PIC (Due
Which can
No. Work Activity Hazard Existing Risk Control (if any) L S R Recommended Control Measure Date/Statu
cause/effect
s)
COS survey and
Miss Coordination with the client
1 marking, key handover Erorr Coordination Coordination 1 1 1
Comunication
and permits
Miss
Mobilization of Coordination with the foreman
2 Comunicatio Erorr Coordination Coordination 1 1 1
workers and management
n
Miss
3 Approval material Comunicatio Erorr Coordination Coordination 1 2 2
n Coordination with the client
Miss Physical injury, Coordination and Use
Using PPE such as glasses or face
4 Material delivery Comunication, extreme weather, of PPE and 1 2 2 shields, gloves, and others
Stuck, delay death understanding of SOP
Ceiling demolition work Hit by material, Use of PPE and Using PPE such as glasses or face
5 Physical injury 1 4 4
for work Stumble understanding of SOP shields, gloves, and others
6 2nd Floor Squeezed,
Reinforcement Scratched,
Physical injury, fire,
WF . iron structure Splashed by Use of PPE and using PPE such as glasses or face
respiratory 2 2 4
installation work grinding, understanding of SOP shields, gloves, and others
obstruction, death
Exposed to
concrete dust
7 Ceiling demolition work Hit by material, Use of PPE and using PPE such as glasses or face
Physical injury 1 4 4
for work Stumble understanding of SOP shields, gloves, and others
 8 Floor Reinforcement 3 Squeezed,
WF . iron structure Scratched,
Physical injury, fire,
installation work Splashed by Use of PPE and using PPE such as glasses or face
respiratory 2 2 4
grinding, understanding of SOP shields, gloves, and others
obstruction, death
Exposed to
concrete dust
9 Cracked wall repair Sprains, Physical injury, fire,
Use of PPE and using PPE such as glasses, gloves,
work exposed to respiratory 2 2 4
understanding of SOP and others
concrete dust obstruction, death
10 Ceiling demolition work Hit by Use of PPE and using PPE such as glasses or face
for work material, Physical injury 1 4 4
Stumble understanding of SOP shields, gloves, and others
11 Rooftop reinforcement Squeezed,
WF . iron structure Scratched,
installation work Splashed by Physical injury, fire, Use of PPE and using PPE such as glasses or face
grinding, respiratory understanding of SOP 1 2 2
Exposed to obstruction, death shields, gloves, and bodyharness
concrete dust
and Fall
12 Perforated Column Sprains,
Repair Work exposed to Physical injury Use of PPE and
understanding of SOP 1 2 2 using PPE such as glasses, gloves,
concrete dust and others

L – Likelihood ;
S – Severity;
R - Risk

Likelihood Rare (1) Remote (2) Occasional (3) Frequent (4) Almost Certain
Severity (5)
Negligible (1) 1 2 3 4 5
Minor (2) 2 4 6 8 10
Moderate (3) 3 6 9 12 15
Major (4) 4 8 12 16 20
Catastrophic (5) 5 10 15 20 25