PT DANONE AQUA GROUP
Contractor's Safety Prequalification - Evaluation Check List
Contractor:
Address:
Phone:
Contact Person:
Contract No.:
Doc. Selection Date:
Site Visit Date:
A B
1. Safety Policy
No written safety/SHE policy in the
company
No communication about safety
policy conducted by management
2. Safety Rules/Manual/Procedures
No written safety/SHE rules or
manual in the company
No 3rd party selection
3. Safety Inspection
No safety inspection plan for auditing
the operation
4. Safety Committee
No safety committee established in
the company
5. Safety Objectives/Programs
No safety objective in the company
PT BERKATMAS MULIA GUNA
12 Okt 2018
SHE policy is existed; not clear in
responsibility & accountability; not
distributed to all employees and not
posted in high visibility areas
Regular communication (at least
Irregular communication about safety
1x/month) about safety policy is
policy is conducted by management;
understanding about safety policy is
conducted by management, level
off understanding
very limited
adequate (>60% of samples),
Safety rules/manual is existed; not
distributed to all employee; less
enforcement
Conducted 3rd party selection,
focused on commercial aspect
Safety inspection plan is existed;
weak in implementation;
management less involved in the
inspection program; no/poor follow-
up actions follow the inspection
Safety committee established in the
company; management less
involved; meeting not conducted
regularly
Safety objective is defined; focused
on lagging indicators
F-SHE-007 Contractor’s Safety Prequalification - Evaluation Check List
C D
SHE policy is existed; clear safety
goals and objectives, clear in
responsibility & accountability;
distributed to all employees;
posted in notice boards
d di off safety
f policy
li isi
Safety rules/manual is existed;
covered existing critical hazards,
distributed to all employees;
actively being enforced; unclear
guideline for disciplinary actions
Conducted 3rd party selection,
focused on commercial & technical
performance aspects
Safety inspection plan is existed;
management actively conduct
regular safety inspection, follow-
up action follow the inspection
Safety committee established in
the company; management
actively led the committee;
meeting conducted regularly (at
least 1x/month)
Safety objectives is defined; safety
leading and lagging indicators;
less monitored and reviewed by
management
Page 1 of 2
PT DANONE AQUA GROUP
Rev. 1
Score %
SHE policy is existed and signed by
top management; clearly establish
safety goals and objectives, Accident
is preventable and zero accident is
attainable, management's
3,0 75,0%
responsibility & accountability;
distributed to all employee; are
posted at most of high visibility areas.
Management actively communicate
safety policy and ensure people's
understanding, level of understanding
is very good (>80%),
( 80%), safety policy is
3 75,0%
driving behind management's
decision, system and procedures
Safety rules/manual is existed;
covered existing critical hazards,
distributed to all employees; actively
being enforced; clear guideline for
3 75,0%
disciplinary actions, reviewed
regularly with employees
Conducted 3rd party selection,
focused on commercial, technical
performance & safety performance
4 100,0%
aspect
Safety inspection plan is existed;
management actively conduct regular
safety inspection, follow-up action
follow the inspection, progress of
3 75,0%
corrective actions are tracked and
monitored
Safety committee established in the
company; management actively led
the committee; meeting conducted
regularly (at least 1x/month); the
committee is supported by the
3 75,0%
improvement teams (sub safety
committees) either standing or ad
hoc committees
Safety objectives is defined; safety
leading and lagging indicators;
actively monitored and reviewed by
management; and the result is used
3,0 75,0%
to improve the on-going safety
program
p g
 A B
Safety program defined to support safety objectives; program
No safety program in the company
that support safety objectives
safety objectives; program
implementation less monitored
C D Score %
Safety program defined to support
safety objectives; program
implementation actively monitored
Safety program defined to support and reviewed, management actively
involved in the program; safety
implementation actively monitored; program also addressing the 2,0 50,0%
program encourage the participation orientation for new or transferred
of the employeess employees; program encourage the
participation of the employees;
safety program also about response
in case of any emergency occured

6. Safety Training & Meeting

The needs for safety training
No safety training established
identified but not implemented
Safety meeting not conducted
No safety meeting conducted
regularly
Safety training needs identified;
safety training implemented but only
for a limited staff only
Safety meeting conducted
regularly and led by the leaders;
corrective action not consistently
discussed
Safety training needs identified;
safety training implemented to all
staff related to work; safety training
2 50,0%
program are regularly reviewed
Safety meeting conducted regularly
and led by the leaders/mgmt;
corrective actions are always
3 75,0%
discussed

7. Progress Motivation Program

There is no program for safety
violation nor reward&recognition for
safety performance in the company
Disciplinary action for safety
Disciplinary action for safety violation
Disciplinary action for safety violation violation is in place; Reward &
is in place; Reward & recognition for
is in place; No reward & recognition recognition for safety
safety performance; Employee has
3 75,0%
for safety performance performance; No procedure for
good access for safety feedback
safety feedback from employee

8. Incident Reporting/Investigation
Procedure for incident reporting &
investigation is in place; corrective
No procedure for the incident
reporting and investigation.
action not monitored & followed up;
no lesson learned shared to
employees
Procedure for incident reporting &
investigation is in place; root caused
of incident clearly identified,corrective
Procedure for incident reporting &
action is monitored & followed up;
investigation is in place; corrective
recommended corrective actions
action is monitored & followed up;
from investigation for improvement
3 75,0%
no lesson learned share to
program; lesson learned is shared to
employee.
employees; safety coordinator &
leaders well trained on incident
investigation

9. Safety Support
Safety organization is established but Safety organization is established Safety organization is established
No safety organization in the
company
accountability & responsibility is not with clear accountability & with clear accountability & 3 75,0%
clear responsibility. responsibility completed with KPI

10. Personal Protective Equipment

Personal Protective Equipment is Personal Protective Equipment is
Personal Protective Equipment is not
No Personal Protective Equipment comply with risk activities provided by company according to
provided by company
complete as risk activities
requirement; no program to the risk activities requirement; has
3 75,0%
requirement
inspect & maintain program to inspect & maintain

11. Safety Performance

No fatality for the last 3 years and 1
Accident record is available and
There is no accident record
updated every month
No fatality for the last 2 years Loss Time Accident for the last one 1 25,0%
year
Safety performance measured and
Safety performance measured and
Safety performance measured and also included safety lagging and
Safety performance not measured
focused on accident only
also included safety lagging and
leading performance; part of
1 25,0%
leading performance;
individual performance evaluation

Total 43 67,2%

Legends: Score: Average Score:

A=1 Minimum = 15 = (Total/64) x 100
B=2 Maximum = 64
C=3
D=4

Page 2 of 2