DOMESTIC TRAVEL & EMERGENCY

RESPONSE PLAN
REX-IND-FRM-1607
Rencana Perjalanan Domestik & Tanggap Darurat

This form must be completed by employees who will travelling domestically for work reasons. A copy
should be sent to destination staff at least two (2) days prior to departure as follow:
Formulir ini harus diisi oleh karyawan yang akan melakukan perjalanan domestik untuk keperluan
pekerjaan. Salinan dokumen ini harus dikirim ke staf yang ditunjuk di tempat tujuan setidaknya dua (2)
hari sebelum keberangkatan,sebagai berikut:

TO Chief Mine Technical Officer / KTT hendra.sebayang@vale.com

pedro.nusa@vale.com
Operation Team moh.ishlahul.aziz@vale.com
roby.syuhada@vale.com
CC dl-stm_ohs@vale.com
OHS Team
Transportation Organiser yusuf.meroekh@vale.com
HR Coordinator utari.kessell@vale.com

DETAILS OF PERSON TRAVELLING

Name/Nama: Joni suwandi

Employer/
Perusahaan: PT Macmahon Mining Services Position/Posisi: Mekanik

Company Address/ The Energy Building 25th Fl. Zone D

Alamat Perusahaan: SCBD Lot 11 A, Jl. Jend. Sudirman Kav. 52-53, Jakarta 12190

Mobile / Hpl: 081353199130 Email: Jonisuwandi1986@gmail.com

Home Address/ Dusun kauman rt 003 rw 001 labuhan sumbawa

Alamat rumah:

Medical:
Tidak ada
Medication/
Pengobatan (yang sedang dijalani/diminum):

Tidak ada
Allergies/Alergi:

Chronic Medical History/ Tidak ada

Riwayat penyakit kronis:

Next of Kin/ Amelia dwi agustin 081227938008

Keluarga Terdekat: Tel:

Print Date: Authorised By Version Number / Date Review Date Page:

30 November 2021 Bede Evans 1 Maret 2020 3 years 1 of 6
C:\Users\eva\Desktop\Domestic Travel and ERP - Eva - Trip01.docForm/Travel/REX-IND-FRM-1607 - Domestic Travel and Emergency Response Plan_090417-to Huu
 DOMESTIC TRAVEL & EMERGENCY
RESPONSE PLAN
REX-IND-FRM-1607
Rencana Perjalanan Domestik & Tanggap Darurat

TRIP OUTLINE/ RINCIAN PERJALANAN

Hu’u Project
Destination/
Tujuan:

STM Emergency– Telp:+62 811 9885 288 (Telkomsel)

Contact Person at Destination/
Kontak Personil di tempat tujuan:

Date Flight No. Flight Origin Destination Depart Arrive

ACCOMMODATION DETAILS

LAND TRANSPORT
Light Vehicle will be arranged by Transportation Organizer

EMERGENCY EQUIPMENT

Map Attached: Yes X No

GSM Signal Availability: Yes X No Type: Telkomsel

Satellite Phone: Yes No X #:

First Aid Kit: Yes X No

GPS Availability: Yes X No

PPE & Extra Equipment:

COVID-19 VACCINATION RECORD

Print Date: Authorised By Version Number / Date Review Date Page:
30 November 2021 Bede Evans 1 Maret 2020 3 years 2 of 6
C:\Users\eva\Desktop\Domestic Travel and ERP - Eva - Trip01.docForm/Travel/REX-IND-FRM-1607 - Domestic Travel and Emergency Response Plan_090417-to Huu
 DOMESTIC TRAVEL & EMERGENCY
RESPONSE PLAN
REX-IND-FRM-1607
Rencana Perjalanan Domestik & Tanggap Darurat

Product Name Joni suwandi

First Dosage 17-11-2021. Dusun Kauman

Date & Location

Second Dosage
Date & Location

COVID-19 Vaccination Card

Print Date: Authorised By Version Number / Date Review Date Page:

30 November 2021 Bede Evans 1 Maret 2020 3 years 3 of 6
C:\Users\eva\Desktop\Domestic Travel and ERP - Eva - Trip01.docForm/Travel/REX-IND-FRM-1607 - Domestic Travel and Emergency Response Plan_090417-to Huu
 DOMESTIC TRAVEL & EMERGENCY
RESPONSE PLAN
REX-IND-FRM-1607
Rencana Perjalanan Domestik & Tanggap Darurat

IN CASE OF EMERGENCY/ DALAM KEADAAN DARURAT

In the event of an emergency, please notify the following emergency contacts immediately/ Jika
terjadi keadaan darurat, mohon memberitahu segera kontak darurat berikut ini:

1. Hendra Sebayang, KTT 4. PT. Sumbawa Timur Mining

Tel: +62 811 499 540 PT. Vale Eksplorasi Indonesia
Sequis Tower, 29th Floor, Jl. Jend.
2. Utari Kessell, HR Sudirman Kav 71,
Tel: +62 81199912383 SCBD, Jakarta Selatan, 12190
Telp: +62 (21) 5085 7450
3. Yan Fuadi, OHS 5. Int’l SOS Alarm Center
Tel: +628122751806 Tel: +62 21 5706001
Project Membership/05APAA096282

RECOMMENDED HOSPITALS / CLINICS

Dompu Bima
RSUD Dompu RSUD Bima
Jl. Kesehatan 1, Dompu Jl Langsat 1 Rabangodu, Rasanae
Tel: +62 (373) 21118/ 21411 Bima 84113 Tel: +62 (374) 43142

Mataram, NTB Jakarta

RS Risa Sentra Medika Rumah Sakit Pondok Indah
Jl. Pejanggik No. 115, Cakranegara, Jl. Metro Duta Kav. UE
Mataram 83231 Tel: +62 (370) 632 117 Pondok Indah, Jakarta 12310 Indonesia
Tel: +62 (21) 765 7525
Denpasar, Bali Fax: +62 (21) 750 2324
RS Kasih Ibu Email: rspi@rspondokindah.co.id
Jl. Teuku Umar No 120, Bali 80114 www.rspondokindah.co.id
Tel: +62 (361) 223 036/237 016

SOS Medika Klinik Bali Singapore

Jl. By Pass Ngurah Rai 505 X Kuta, Bali Raffles Hospital Pte. Ltd.
Tel : +62 361 710505 / 720100 Address: 585 North Bridge Road #01-00,
Singapore 188770
Tel: + 65 6311 1111 (General); 6311 1555
(A&E) / +65 6311 1222 (24 hrs General
Appt)
+65 6311 1666 (IPC) / +65 9828 3784
(IPC) (mobile)

Print Date: Authorised By Version Number / Date Review Date Page:

30 November 2021 Bede Evans 1 Maret 2020 3 years 4 of 6
C:\Users\eva\Desktop\Domestic Travel and ERP - Eva - Trip01.docForm/Travel/REX-IND-FRM-1607 - Domestic Travel and Emergency Response Plan_090417-to Huu
 DOMESTIC TRAVEL & EMERGENCY
RESPONSE PLAN
REX-IND-FRM-1607
Rencana Perjalanan Domestik & Tanggap Darurat

MAPS

Print Date: Authorised By Version Number / Date Review Date Page:

30 November 2021 Bede Evans 1 Maret 2020 3 years 5 of 6
C:\Users\eva\Desktop\Domestic Travel and ERP - Eva - Trip01.docForm/Travel/REX-IND-FRM-1607 - Domestic Travel and Emergency Response Plan_090417-to Huu
 DOMESTIC TRAVEL & EMERGENCY
RESPONSE PLAN
REX-IND-FRM-1607
Rencana Perjalanan Domestik & Tanggap Darurat

Print Date: Authorised By Version Number / Date Review Date Page:

30 November 2021 Bede Evans 1 Maret 2020 3 years 6 of 6
C:\Users\eva\Desktop\Domestic Travel and ERP - Eva - Trip01.docForm/Travel/REX-IND-FRM-1607 - Domestic Travel and Emergency Response Plan_090417-to Huu