Nomor Formulir

SHE.FRM.003.R00
Cabang / Branch : Form Number

PENILAIAN RISIKO
RISK ASSESSMENT
Efek Bahaya / Dampak Matriks Tanpa Pengendalian
Benda / Bahan / Aktivitas Kerja / Kondisi Daerah Waktu Peralatan Bahaya / Aspek
Hazard Effect / Impact Matrix Without Control Measure
No Manusia Property Lingkungan Peluang (P) Keparahan Nilai Risiko
Items / Materials / Activity / Condition Area Time Tooling Hazard / Aspect Risk Total
Human Property Environment Probability Severity (S)
1 2 3 4 5 6 7 8 9 10 11 12

Bagian dari / Part of - SHE.SOP.003.R00 Halaman / Page 1

 Nomor Formulir
SHE.FRM.003.R00
Cabang / Branch : Form Number

PENILAIAN RISIKO
RISK ASSESSMENT
Efek Bahaya / Dampak Matriks Tanpa Pengendalian
Benda / Bahan / Aktivitas Kerja / Kondisi Daerah Waktu Peralatan Bahaya / Aspek
Hazard Effect / Impact Matrix Without Control Measure
No Manusia Property Lingkungan Peluang (P) Keparahan Nilai Risiko
Items / Materials / Activity / Condition Area Time Tooling Hazard / Aspect Risk Total
Human Property Environment Probability Severity (S)
1 2 3 4 5 6 7 8 9 10 11 12

Bagian dari / Part of - SHE.SOP.003.R00 Halaman / Page 2

 Nomor Formulir
SHE.FRM.003.R00
Cabang / Branch : Form Number

PENILAIAN RISIKO
RISK ASSESSMENT

Tindakan Pengendalian / Control Measure Matriks Dengan Pengendalian

Benda / Bahan / Aktivitas Kerja / Kondisi Daerah
Teknikal / Technical Administrasi / Administration Matrix With Control Measure
No
Eliminasi Substitusi Eng/Separasi Prosedur/WIN Pelatihan APD PPE Peluang (P) Keparahan Sisa Risiko
Items / Materials / Activity / Condition Area Residual Risk
Elimination Substitution Eng/Separation Procedure/WIN Training Probability Severity (S)
1 2 3 13 14 15 16 17 18 19 20 21
Bagian dari / Part of - SHE.SOP.003.R00 Halaman / Page 3
 Nomor Formulir
SHE.FRM.003.R00
Cabang / Branch : Form Number

PENILAIAN RISIKO
RISK ASSESSMENT

Tindakan Pengendalian / Control Measure Matriks Dengan Pengendalian

Benda / Bahan / Aktivitas Kerja / Kondisi Daerah
Teknikal / Technical Administrasi / Administration Matrix With Control Measure
No
Eliminasi Substitusi Separasi/Rek Prosedur/WIN Pelatihan APD PPE Peluang (P) Keparahan Sisa Risiko
Items / Materials / Activity / Condition Area Residual Risk
Elimination Substitution Separation/Eng Procedure/WIN Training Probability Severity (S)
1 2 3 13 14 15 16 17 18 19 20 21

Disusun Oleh / Propose by Diperiksa Oleh / Checked by Disetujui Oleh / Approved by Halaman
Section Head SHE Department Department Head 4
Tanggal / Date

Nama / Name Nama / Name Nama / Name Revisi / Revision

Bagian dari / Part of - SHE.SOP.003.R00