Fakultas Teknik Date of issue

1-Dec-23
Page 1 of 7
Universitas Diponegoro

Title : "Work Permit Form"

Originator : P2K3 Fakultas Teknik

Document Type : P New Revision

Nature of Revision :

Reason of revision

Approval in sequence:

Function Name Sign Date

Koordinator P2K3
Fakultas Teknik
Manajer Fakultas
Teknik
Wakil Dekan Sumber
Daya Fakultas Teknik

Date Of Print : 12/01/2023

 Fakultas Teknik Date of issue
1-Dec-23
Page 2 of 7
Universitas Diponegoro

Title : "Work Permit Form"

1.0 Scope
This form is used for getting clearance for executing the job in any location at Faculty of Engineering,
Diponegoro University.

This form is also used as a tool for communication between work group and process people or
department owner.

2.0 List of Form

Work permit Form

3.0 Record
This collection is filed in the department area and kept by concern Head of OSH Unit for one month.

In case accident occurred work permit related to the job will be filed in Faculty's OSH Unit/P2K3 FT and
kept for 5 years.

Date Of Print : 12/01/2023

 Title : "Work Permit Form"

709293249.xlsx Date of print : 12/01/2023

 WORK PERMIT / IZIN KERJA
NO:
TO BE FILLED IN BY DEPARTMENT'S OSH UNIT
Diisi oleh K3 Departemen
Working in hazardous area Working with fire and/or The works are Working on Height
and in confined space explosion hazard considered need written communication
Bekerja di area berbahaya/ruang tertutup/terbatas Bekerja dg api/bahaya ledakan Bekerja dimana diperlukan komunikasi secara tertulis Bekerja di ketinggian

Department : Building : Equipment: This W/P is valid for : ……. Days

Departemen/ dimana pekerjaan mau dilakukan Gedung/lokasi Peralatan yang akan dikerjakan W/P ini berlaku selama: …….. Hari
Scope of work: Emergency / break down Planned work
Cakupan pekerjaan Pekerjaan yang sifatnya emergency Pekerjaan yang direncanakan
Tools to be used: Jack hammer / welding machine / gas cutting / grinding / radiographic
Certificate for tools necessary: Yes/ No
Working height ( approx): above 1 m / above 2 m/ above 5 m/ above 10 m
Scafolding required: Yes/ No
Work group / contractor who do the work Responsible person to get the work done / W.G Leader/Attendant Authorized person to do the work/entrant

Group / Kontraktor yang melakukan pekerjaan Nama Orang yang melaksanakan pekerjaan/mengawasi Orang yang melakukan pek/yang masuk C.Space

Name of originator: Signature: Department :

Nama yang memberi ijin kerja Tandatangan Departemen pemberi kerja
Possible Hazard Lack of 02 / kekurangan oksigen Toxic Gas / gas beracun Mechanical / mekanis
Kemungkinan Combustible gas/gas mudah terbakar Toxic Vapor / uap beracun Temperature / temperatur
Bahaya Combustible vapor/uap mudah terbakar Chemical contact / terkena bahan kimia Engulfment / tertelan
Combustible dust/debu mudah terbakar Electrical Hazard / bahaya listrik Entrapment / terperangkap

A. Safety Meassure Before the Work done / Tindakan Safety sebelum pekerjaan dimulai
1. Stop Equipment ( Describe ) = Stop mesin / peralatan , (Jelaskan) -
2. Flushing & cleaning = Pembilasan dan pembersihan
3. Blind / disconnect any pipe = Tutup / putuskan hubungan ke setiap pipa Process Isolation form No. :
4. Necessary to make free of Electric power = Perlukah memutuskan hubungan listrik Power Isolation form No. :
5. Measures against Radioactive Hazards = Pencegahan terhadap bahaya radio aktif Nomor formulir isolasi

6. Necessity to isolate the work site = Perlu mengamankan mengisolasi lokasi kerja
7. Ventilation = Pembilasan dan ventilasi Note :must for confined space job
8. Measure against ignition / fire = Pencegahan terhadap bahaya terbakar.
9. Prepare for Environment Meassures = Siapkan tindakan untuk lingkungan Inform P2K3
10. Further Meassure / Extra Meassure = Tindakan lain / tindakan tambahan
TEST TAKEN TLV/NAB TIME RESULT TEST TAKEN TLV/NAB TIME RESULT
11. Gas Analysis /Analisa gas
% of O2 19.5-21% CS2 10 ppm
Combustible gas < 10%LEL NH3 25 ppm
Initial tester / orang yang menganalisa
H2S 10 ppm OTHERS
12. Frequency of testing 30 mins / 1 hr / 2 hr / 4 hr / Continuous
B. Safety Measure During the Work Done / Tindakan Safety pada saat pekerjaan berlangsung
1. Ventilation = Ventilasi Note : must for confined space job
2. Use low voltage electrical equipment, 24 VOLT = Gunakan peralatan listrik dengan tegangan rendah, 24 VOLT
3. Use the gas mask (Air line gas mask) if concentration > 10 ppm = Gunakan masker gas (udara) jika konsentrasi >10 ppm
4. Chemical resistant Clothing, Glove, Glasses = Pakaian anti bahan kimia, sarung tangan, kaca mata
5. Use Full body harness &Rope = Gunakan pengaman tubuh sepenuhnya dan tali
6. Attendant / Rescuer / Safety man required = Pengamatan / Penyelamatan / personil safety diperlukan Note:
must for confine job
7. Special tools during the work done = alat khusus selama pekerjaan berlangsung
8. Measures against fire = Tindakan terhadap api (Hydrant, Fire Extinguisher)
9. Rescue equipment = Peralatan penyelamatan Ambulence/Fire truck/ Air line masker/O2 cyl Note: must for confine job
10. Continuous monitoring working condition / pemantauan kontinyu kondisi kerja
11. Safety Coordinator /Koordinator Safety Name / Nama Telp.
12. Environment Measure during the work = Langkah-langkah pengamanan terhadap selama pekerjaan berlangsung

Name who give clearance Time to start (date/time) Clearance given after control all measures
Nama yang memberi kan ijin Waktu mulai (tgl/jam) Ijin diberikan setelah kontrol semua tindakan pencegahan telah dilakukan

Time to stop (date /time)

Waktu berhenti (tgl/jam)
Date Signature of responsible person / Supervisor (process)
This work will be allowed if the above meassure are carried out. I have understood about Safety meassure and obliged to follow
(Pekerjaan ini boleh dimulai bila semua pencegahan tersebut diatas sudah dilakukan) Saya mengerti tentang tindakan-tindakan keselamatan dan wajib diikuti.
Date / Tgl :
Date / Tgl Signature of Faculty's OSH Unit Signature of work group leader/attendant :
Tanda tangan perwakilan P2K3 FT Tanda tangan pimpinan kerja
Signature of responsible person from service dept :
Tanda tangan orang yang bertanggung jawab dari departemen
Green : Work Group Leader/ at site
Yellow : Ketua K3 Departemen
White : P2K3 FT

*) For further analysis please see the next page Untuk analisa selanjutnya, silahkan dilihat halaman berikutnya
 WORK PERMIT / IJIN KERJA
SN:
TO BE FILLED IN BY DEPARTMENT'S OSH UNIT
Diisi oleh K3 Departemen.
Working in hazardous area Working with fire and/or The works are Working on Height
and in confined space explosion hazard considered need written communication
Bekerja di area berbahaya/ruang tertutup/terbatas Bekerja dg api/bahaya ledakan Bekerja dimana diperlukan komunikasi secara tertulis
Department : Building : Equipment: This W/P is valid for : 8 H rs
Departemen/ dimana pekerjaan mau dilakukan Gedung/lokasi Peralatan yang akan dikerjakan W/P ini berlaku selama Jam
Kind of work: (see attachment) Emergency / break down Planned work
Jenis Pekerjaan Pekerjaan yang sifatnya emergency Pekerjaan yang direncanakan
Tools to be used: Jack hammer/welding machine/gas cutting /grinding /radiographic
Certificate for tools necessary Yes/ No
Working height ( approx) above 1 m / above 2 m/ above 5 m/ above 10 m
Scafolding required Yes/ No
Work group / contractor who do the work Responsible person to get the work done / W.G Leader/Attendant Authorized person to do the work/entrant

Group / Kontraktor yang melakukan pekerjaan Nama Orang yang melaksanakan pekerjaan/mengawasi Orang yang melakukan pek/yang masuk C.Space
Name of originator:.................. Signature:......................... Department : .......................
Nama yang memberi kerja Tandatangan Departemen pemberi kerja / service dept

TO BE FILLED IN BY DEPARTMENT'S OSH UNIT Date / Tgl :

Diisi oleh K3 Departemen.

Possible Hazard Lack of 02 / kekurangan oksigen Toxic Gas / gas beracun Mechanical / mekanis
Kemungkinan Combustible gas/gas mudah terbakar Toxic Vapor / uap beracun Temperature / temperatur
Bahaya Combustible vapor/uap mudah terbakar Chemical contact / terkena bahan kimia Engulfment / tertelan
Combustible dust/debu mudah terbakar Electrical Hazard / bahaya listrik Entrapment / terperangkap

A. Safety Meassure Before the Work done / Tindakan Safety sebelum pekerjaan dimulai
1. Stop Equipment ( Describe ) = Stop mesin / peralatan , (Jelaskan) -
2. Flushing &cleaning = Pembilasan dan pembersihan
3. Blind / disconnect any pipe = Tutup / putuskan hubungan ke setiap pipa Process Isolation form No. :
4. Necessary to make free of Electric power = Perlukah memutuskan hubungan listrik Power Isolation form No. :
5. Measures against Radioactive Hazards = Pencegahan terhadap bahaya radio aktif Nomor formulir isolasi

6. Necessity to isolate the work site = Perlu mengamankan mengisolasi lokasi kerja
7. Ventilation = Pembilasan dan ventilasi Note :must for confined space job
8. Measure against ignition / fire. = Pencegahan terhadap bahaya terbakar.
9. Prepare for Environment Meassures = Siapkan tindakan untuk lingkungan Inform security / Safety / CSR
10. Further Meassure / Extra Meassure = Tindakan lain / tindakan tambahan
TEST TAKEN TLV/NAB TIME RESULT TEST TAKEN TLV/NAB TIME RESULT
11. Gas Analysis /Analisa gas
% of O2 19.5-21% CS2 10 ppm
Initial tester / orang yang menganalisa Combustible gas < 10%LEL NH3 25 ppm
H2S 10 ppm OTHERS

12. Frequency of testing 30 mins / 1 hr / 2 hr / 4 hr / Continuous

B. Safety Measure During the Work Done / Tindakan Safety pada saat pekerjaan berlangsung
1. Ventilation = Ventilasi Note : must for confined space job
2. Use low voltage electrical equipment, 24 VOLT = Gunakan peralatan listrik dengan tegangan rendah, 24 VOLT
3. Use the gas mask (Air line gas mask) if concentration > 10 ppm = Gunakan masker gas (udara) jika konsentrasi >10 ppm
4. Chemical resistant Clothing, Glove, Glasses = Pakaian anti bahan kimia, sarung tangan, kaca mata
5. Use Full body harness &Rope = Gunakan pengaman tubuh sepenuhnya dan tali
6. Attendant / Rescuer / Safety man required = Pengamatan / Penyelamatan / personil safety diperlukan Note: must for confine job
7. Special tools during the work done = alat khusus selama pekerjaan berlangsung
8. Measures against fire = Tindakan terhadap api (Hydrant, Fire Extinguisher)
9. Rescue equipment = Peralatan penyelamatan Ambulence/Fire truck/ Air line masker/O2 cyl Note: must for confine job
10. Continuous monitoring working condition / pemantauan kontinyu kondisi kerja
11. Safety Coordinator /Koordinator Safety Name / Nama Telp.
12. Environment Measure during the work = Langkah-langkah pengamanan terhadap selama pekerjaan berlangsung
Name who give clearance Time to start (date/time) .......................... Waktu mulai Clearance given after control all measures = ijin diberikan setelah kontrol semua tindakan pencegahan telah
Nama yang memberi kan ijin (tgl/jam) dilakukan
Time to stop (date /time) .......................... Waktu
berhenti (tgl/jam) Date Signature of responsible person / Supervisor (process)
This work will be allowed if the above meassure are carried out. I have understood about Safety meassure and obliged to follow
(Pekerjaan ini boleh dimulai bila semua pencegahan tersebut diatas sudah dilakukan)
Saya mengerti tentang tindakan-tindakan keselamatan dan wajib diikuti.

Date / Tgl :
Date / Tgl Signature of Manager or DEPUTY Signature of work group leader/attendant :
Tanda tangan HOD atau wakilnya. Tanda tangan pimpinan kerja
Signature of responsible person from service dept :
Tanda tangan orang yang bertanggung jawab dari service dept.
Green : Work Group Leader/ at site
Yellow : Supervisor Process/ Control Room
White : HOD/ Deputy Process

*) For further analysis please see the next page

Untuk analisa selanjutnya, silahkan dilihat halaman berikutnya
Further Analysis / continuous monitoring= Analisa selanjutnya

TLV / NAB Time / Test 1 Time / Test 2 Time / Test 3 Time / Test 4
Medium / Media
waktu waktu waktu waktu
% of O2 19.5 - 21%
Combustible gas < 10% LEL
H2S < 10 ppm
CS2 < 10 ppm
CO < 25 ppm
SO2 < 2 ppm
NH3 < 25 ppm
Others

Name/Initial of tester = Nama/Inisial orang yang menganalisa : ……………………………………..

Time extension = Waktu perpanjangan `

This work permit is extended till: ………….. …………….. …………………………………………..

Ijin kerja ini diperpanjang sampai Date/Tgl Time/waktu
Signature of assigned supervisor
Tanda tangan Supervisor yang diberi tugas

Till/sampai : …………. …………… ……………………………………………

Date/Tgl Time/waktu
Signature of assigned supervisor
Tanda tangan Supervisor yang diberi tugas

Change of the work group = Pergantian group kerja

I have read and understood the safety measures and had to follow it.
Saya telah membaca dan mengerti tindakan keselamatan dan harus dipatuhi

Work group leader Name Time Signature

Work group leader

Work group leader

Work group leader

Work group leader

Before checking out, take care house keeping = Sebelum meninggalkan kerja, bersihkan tempat kerja

Finishing the work = Penyelesaian pekerjaan

The work was finished at: ………………… ………….

………………………………………….
Pekerjaan telah selesai pada : Time /Waktu Date/Tgl Signature of assigned supervisor
Tanda tangan Supervisor yang diberi tugas

………………………………………….
Working place is taken over Signature of Head of Department's OSH Unit
Tempat kerja telah diserah terimakan Tanda tangan Ketua Tim K3 Departemen

Unit K3 Fakultas Teknik UNDIP Printed 12/01/2023, 15:44:45