LAMPIRAN

FORM PCRA RS BHAKTI HUSADA II PURWAKARTA

Risk Criteria Yes No Comments

1. Will the construction directly affect
patient care areas?

2. Does the construction area contain

any environmental hazards?
Asbestos
Chemicals
Others

3. Air Quality
A. Has the location of the outside air
intakes been taken into
consideration?
B. Will the HVAC system need to be
rebalanced prior to construction to
ensure propser air flow
requirements?

4. Are Utility Shut Downs Required

(check below)
Fire Detection System
Sprinkler
Electric
HVAC
Hot / Cold Domestic Water
Sanitary
Steam
Other
___________________________

5. Will construction activities create

enough noise to be disruptive?

6. Will construction activies cause

enough vibration to be disruptive?

7. Will contractor deliveries or debris

removal be made outside of normal
working hours?

8. Will debris removal require more

than standard precautions (removal
in covered carts wiped down with
disinfectant)?
 Pre-Construction Risk Assessment (PCRA)

Project Name: Project Location:

FDC# Project Manager:
Architect: Contractor:
Project Description:

See page 2 for additional information, interventions or action plans

YES NO
A. Will construction directly affect patient care areas?
Spaces adjacent to, above and below the construction area must be considered.
B. Will HVAC systems be affected by the construction (i.e., outside air intakes, exhaust
systems, air handlers)? If yes, note which systems and provide an action plan.
C. Are Utility Shut Downs Required? Check all that apply.
HVAC Steam
Hot / Cold Domestic Water Medical Gas
Sanitary Electric
Other (Specify):
ALL utility shut downs must be coordinated with contractor, Facilities Services, affected departments and hospital
administration in order to minimize disruption to operations.
D. Will construction activities generate noise that will disrupt occupants adjacent to,
above, or below the construction area?
a. If yes, affected occupants must be notified.
b. How will work be managed to minimize disruption?
 E. Will construction activities generate vibration that will disrupt occupants adjacent to,
above, or below the construction area?
a. If yes, affected occupants must be notified.
b. How will work be managed to minimize disruption?

F. Does the construction area contain any environmental hazards?

Asbestos Chemicals (Specify):
Other (Specify):

G. Will contractor deliveries or debris removal be made outside of normal working hours?
If yes, describe hours and any special requirements.

H. Will debris removal require precautions above and beyond those required for the
assigned ICRA precaution level? (i.e., covered carts, wiped down for levels III-IV)
If yes, describe additional precautions.

I. Are there any other circumstances that may affect care, treatment and services?

YES NO
Has an ICRA been developed for this project?
Date Reviewed _______________________ ICRA Level Assigned _________________

Reviewed by: Date:

TJC Standard EC 02.06.05 states that space must be managed during demolition, renovation or new construction to reduce risk to those in the
organization. This form addresses Element of Performance 2. An ILSM must be completed to comply with Element of Performance 3 (See ILSM for
Construction and Renovation Projects Form). An ICRA must be completed to comply with Element of Performance 3 (See Infection Control Risk

Page 2 Pre-Construction Risk Assessment (PCRA)

ADDITIONAL INFORMATION

Project Name: Project Location:

FDC# Project Manager:
Architect: Contractor:

YES NO
A. Spaces that will be affected:

B. HVAC systems affected by the construction:

C. Utility Shutdowns with greater than usual impact:

D. Construction activities generating disruptive noise:

 E. Construction activities generating disruptive vibration:

F. Environmental hazards requiring special attention:

G. Deliveries or debris removal made outside of normal working hours:

H. Debris removal require precautions above and beyond those required for the
assigned ICRA precaution level?

I. Are there any other circumstances that may affect care, treatment and services?

Reviewed by :
Initials
 No Dok :

Ahli K3 RS SURAT IZIN PEKERJAAN RESIKO TINGGI No Rev : 0

Tgl Rilis :
Hal : 1/1
Nomor: 01/IK/OHS/IX/2018 Tanggal:
A. KLASIIKASI PEKERJAAN
Ruang Terbatas Kerja Listrik Ketinggian Alat Berat Persiapan Tangki
B. INFORMASI PEKERJAAN
Pekerjaan Daftar Pekerja Jumlah
Lokasi Teknisi
Area Surveyor
Operator Alat berat
Nama Karu Rigger
Telp Karu Teknisi Elektrik
Nama Pemohon Mekanik
Telp Pemohon Welder
Pengawas Fitter
Telp Pengawas Tukang Bangunan
Petugas K3RS Tukang Kayu
Telp Petugas K3RS Helper
Perusahaan Pemohon Lainnya :
C. PERLENGKAPAN KERJA
Alat jml Mesin Jml Material Jml Alat Berat Jml
Kuas 1 Cat 1 fill
Lakban Kertas 2 Tiner 1 kaleng
Steager 1
Telescopic 1
* semua perlengkapan kerja diperiksa oleh K3RS
D. KESELAMATAN KERJA
No Aktivitas Potensi Bahaya Langkah Aman Pekerjaan
1 Pengecatan Cat Tumpah Menggunakan Sarung Tangan Karet
*Identifikasi bahaya dijadikan sebagai panduan bekerja secara aman dan selamat
E. PERALATAN KESELAMATAN
Alat Pelindung Diri Perlengkapan Keselamatan & Darurat
Helm Earplug/Earmuff Pelampung Pemadam API (APAR)
Kacamata Google Sarung Tangan Karet Baju Lab Barkode
Tameng Muka Sarung Tangan Kebun Sepatu Keselamatan Rambu/tanda Keselamatan
Kop Las Sarung Tangan Kulit Sepatu Boots LOTO
Masker Kain Sarung Tangan Las Tabung Pernapasan Radio Telekomunikasi
Masker Kimia Sabuk Keselamatan Apron Jaring/ Tali Keselamatan
Full Body Harnes Lainnya: Lainnya:
F. VALIDASI IZIN KERJA
Izin Diberikan Izin Lembur Izin Dibatalkan
Mulai Jam : 08:00 Mulai Jam : Jam
Sampai Jam : 16:00 Sampai Jam : Keterangan
Disiapkan Disiapkan Disiapkan
Pemohon Perusahaan Pemohon
Nama : Nama : Nama :
Tanggal : Tanggal : Tanggal :
Diperiksa Diperiksa Diperiksa
Pengawas K3 Pengawas K3 Pengawas K3
Nama : Nama : Nama :
Tanggal : Tanggal : Tanggal :
Mengetahui Mengetahui Mengetahui
Karu Area Karu Area Manajer Area
Nama : Nama : Nama :
Tanggal : Tanggal : Tanggal :
*Catatan Lain:

*Putih unruk Pengawas K3, Kuning untuk Pemohon, Merah untuk Manajer Area
 FORM LAPORAN INSIDEN

LAPORAN KECELAKAAN

I. DATA PERSONAL
Nama :
Ruangan :
Umur :

II. RINCIAN KEJADIAN

1 Tanggal dan waktu insiden
Tanggal :
2 Insiden :
3 Kronologis insiden
...................................................................................................................
...................................................................................................................
4 Orang pertama yang melaporkan insiden
Karyawan
Pasien
Keluarga
Pengunjung
Lain-lain
5 Insiden terjadi pada*
Pasien
Lain-lain
Mis: Karyawan/pengunjung/pendamping/keluarga pasien, lapor ke K3RS

6 Insiden menyangkut pasien

Pasien rawat inap
Pasien rawat jalan
Pasien UGD
Lain-lain
7 Tempat insiden
Lokasi kejadian
....................................................................................................................
8 Akibat insiden terhadap pasien*
Kematian Cedera irreversible
Cedera reversible Cedera ringan
Tidak ada cedera
9 Tindakan yang dilakukan segera setelah kejadian, dan hasilnya
................................................................................................................
................................................................................................................

10 Tindakan
dilakukan
oleh*
Tim: Terdiri dari............................................................................
Dokter
Perawat
Petugas lainnya
11 Apakah kejadian yang sama pernah terjadi di Unit Kerja lain?*
Ya Tidak
 Apabila ya, isi bagian dibawah ini.
Kapan? Dan langkah/tindakan apa yang telah diambil pada Unit kerja
tersebut untuk mencegah terulangnya kejadian yang sama
................................................................................................................
Grading risiko kejadian* (duusu oleh atasan pelapor)
Tindak lanjut* (diisi oleh atasan pelapor):
Investigasi sederhana 1 minggu
Investigasi sederhana >1 minggu
RCA 45 Hari
NB*= pilih satu jawaban

Penerima
Pembuat
Laporan/Atasan
Laporan
langsung

Paraf
Paraf

Tgl Lapor Tgl Lapor

Tim Pengendalian Risiko

Grading risiko kejadian* (Diisi oleh atasan pelapor):
Tindak lanjut* (diisi oleh atasan pelapor) :
Investigasi sederhana 1 minggu
Investigasi sederhana >1 minggu
RCA 45 Hari

Nama jelas :
Tanda tangan :
Tanggal :
Jam :
 FORM IDENTIFIKASI RISIKO

AKTIVITAS RISIKO RISK

NO RUANGAN P D R GRAD
KERJA TERIDENTIFIKASI CONTROL