Doc. No.

: 26071-100-GPP-GHX-00025

Job No.: 26071 Rev. 001

ILLNESS NOTIFICATION AND REPORTING

PROCEDURE
PROJECT : Engineering, Procurement, Construction for Refinery
Development Master Plan (RDMP) RU V Balikpapan
LOCATION : Refinery Unit V Balikpapan, East Kalimantan,Indonesia
OWNER : PT PERTAMINA (Persero)

001 09 SEP 19 ISSUED FOR YUZAR ISPRANTO K.A Y.D.KIM

CONSTRUCTION
000 15 AUG 19 ISSUED FOR YUZAR ISPRANTO K.A Y.D.KIM
CONSTRUCTION
00A 15APR 19 ISSUED FOR REVIEW YUZAR ISPRANTO K.A Y.D.KIM

REV. DATE DESCRIPTION PREPARED CHECKED APPROVED

 Doc. No. : 26071-100-GPP-GHX-00025

Job No.: 26071 Rev.001

REVISION LOG

REV. NO. DATE PAGE DESCRIPTION

00A 15APR 19 ISSUED FOR REVIEW

000 18 AUG 19 5,6,7,8 REVISED AS PMC COMMENT
001 09 SEP 19 Accept all changes and submit final clean copy

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 Doc. No. : 26071-100-GPP-GHX-00025

Job No.: 26071 Rev.001

Table of Contents

1. PURPOSE................................................................................................................................................. 4
2. SCOPE ...................................................................................................................................................... 4
3. DEFINITION ........................................................................................................................................... 4
4. REFERENCE ........................................................................................................................................... 5
5. RESPONSIBILITIES .............................................................................................................................. 5
5.1 Project manager ......................................................................................................................................... 5
5.2 Construction Manager ............................................................................................................................... 5
5.3 Construction Superintendent...................................................................................................................... 5
5.4 HSE Manager............................................................................................................................................. 5
5.5 HSE Chief .................................................................................................................................................. 5
5.6 HSE Superintendent & Supervisor ............................................................................................................ 5
5.7 SITE DOCTOR ......................................................................................................................................... 6
5.8 HEALTH/ MEDICAL ADVISOR ............................................................................................................ 6
5.9 PARAMEDIC ............................................................................................................................................ 6
5.10 Employee ................................................................................................................................................... 6
6. DETAILS PROCEDURES ..................................................................................................................... 6
6.1 Notification and Communication Channel ................................................................................................ 7
6.2 Emergency Contact Number ...................................................................................................................... 7
6.3 Reporting and Investigation ....................................................................................................................... 7

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 Doc. No. : 26071-100-GPP-GHX-00025

Job No.: 26071 Rev.001

1. PURPOSE

This procedure describes the reporting protocol for serious illnesses personnel occurred on site
This procedure also to support prevention, treatment & rehabilitation of illness personnel,
especially for possible work related illness
Occupational illness resulting of exposures to work or work environment, must be handle
carefully due to this is recordable to project achievement

2. SCOPE

This procedure covers the reporting of Serious illness in RDMP Balikpapan JO.Procedure for
reporting injury shall refer to Doc. No : 20671-100-GPP-GHX-00019 (Incident Investigation And
Reporting Procedure)

3. DEFINITION

Project : Engineering Procurement Construction for Refinery

Development Master Plan (EPC for RDMP) RU-V Balikpapan
Company : PT. Pertamina (Persero)
Contractor : RDMP Balikpapan JO
Subcontractor : Successful BIDDER(s) appointed by Contractor to provide
services to Contractor
Hazard : A condition or situation which has the potential to cause injury or
illness.
Incident : Any occurrence that leads to, or might have led to, injury or
illness to people, danger to health and/or damage to property or
the environment. For the purpose of this procedure, the term
"incident" is used as an inclusive term for injuries/illnesses,
accidents and near misses.
Near miss : Any occurrence that might have led to injury or illness of a
person.
Injury : Injury also known as physical trauma, is damage to the body caused by
external force. This may be caused by accidents, falls, hits, weapons,
and other causes. Injuries include cases such as, a cut, fracture, sprain or
amputation
Illness : Illness is feelings of discomfort, pain or unease in people,
illness include both acute & chronic disease, such as, a skin disease,
respiratory disorder or poisoning
The "common cold" or influenza ("flu") is non work related illness.
However, in the case of other infectious diseases such as malaria,
dengue fever, tuberculosis, brucellosis, and hepatitis C, contractor will
evaluate reports of such illnesses for work relationship

Occupational illness : Illness resulting of exposures to work or work environment

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Job No.: 26071 Rev.001

4. REFERENCE

• Regulation of the Minister of Manpower No. 5/2018 regarding Occupational Health and
Safety
• Goverment Regulation no.7/2019 regarding Occupational Illness
• Regulation of the Minister of Health No. 70/2016 regarding industrial work environment
standards & requirements
• Regulation of the Minister of Manpower No.3/1998 regarding procedure for accident
reporting & investigation
• HSE Plan Doc. No. : 26071-100-G01-GHX-00001
• Project Emergency Handling Procedure Doc. No. : 26071-100-GPP-GHX-00002
• Incident Investigation and Reporting procedure Doc. No. : 26071-100-GPP-GHX-00019

5. RESPONSIBILITIES

5.1 PROJECT MANAGER

• Ensure the effective implementation of this procedure.
• Review the circumstances of serious work injuries or illnesses including the progress of
implementation of corrective action plans.

5.2 CONSTRUCTION MANAGER

• Implementing this procedure and ensure all site personnel including visitor

5.3 CONSTRUCTION SUPERINTENDENT

• Reporting for every illness occurs to site doctor or nearest HSE personnel
• Involving in incident investigation

5.4 HSE MANAGER

• Ensure the Serious illness employee is given subsequent treatment if necessary; however
only Confirmed Occupational illness is recorded

5.5 HSE CHIEF

• Complete an Accident/Incident Reporting Form and distributed to the appropriate parties
including the employee.
• Implement corrective action to reduce the loss exposure / risk of injury and to prevent
future unsafe work practices, as necessary and/or as recommended by the safety
committee.

5.6 HSE SUPERINTENDENT & SUPERVISOR

• Assist HSE Chief for accident / incident investigation & reporting by provide correct data i

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Job No.: 26071 Rev.001

5.7 SITE DOCTOR
• Review & Verify MCU result, ensure worker are fit for job position.
• Conduct Site Clinic to deliver primary medical care, minor surgery and consultation.
• Prepare referral case, coordinate with hospital & conduct Medical evacuation.
• Conduct Occupational Health Management system, include Prior to work. Medical Examination,
Return to Work, Recording & Reporting.
• Deliver Prompt Treatment for Emergency cases.
• Alert to work related illness / injury may be found while doing the role above
• Deliver Medical Notification Note (attached) to IP supervisor & Chief HSE

5.8 HEALTH/ MEDICAL ADVISOR

• Review Illness Notification & Reporting Procedure.
• Provide advice for Doctor, IH & Paramedic on site.
• Confirm Work related illness

5.9 PARAMEDIC
• Respond immediately and deliver initial stabilization for injured / illness person at the scene prior
transfer to site clinic.
• Assist Site Doctor in implementation of health management programs,
• Assist Site Doctor to identify health hazards in the work place, implement control and monitoring
program

5.10 EMPLOYEE
• An employee who sustains an injury or becomes ill as a result of workplace conditions or
work activity must verbally report the injury or illness to any manager/supervisor
immediately (not necessarily their own).

6. DETAILS PROCEDURES

Contractor will provide site clinic for Primary treatment & Health-Medical Program, Any
suspicious work related illness case(s) found, should be evaluated & investigated by Health
Advisor. If still any doubt, Health advisor may consult the case to Medical consultant / specialist.
Contractor will provide site clinic for Primary treatment & Health-Medical Program, Any
suspicious work related illness case(s) found, should be evaluated & investigated by Health
Advisor. If still any doubt, Health advisor may consult the case to Medical consultant / specialist

Health Medical Advisor & Chief HSE should immediately report Confirmed Occupational
illness case(s) to Project Manager, Project HSE Manager& Contruction Manager.

Construction Manager should provide full support to the possible work related illness personnel,
to include: appropriate treatment, transportation & escorting to medical facility, assist insurance
claim process, etc. Site Doctor will provide Medical Notification to explain patient condition &
maintain confidentiality

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Job No.: 26071 Rev.001

6.1 NOTIFICATION AND COMMUNICATION CHANNEL

Serious
illness HSE
Manager

Onsite
Doctor

Health Chief HSE Construction Project Company

Advisor Manager Manager

6.2 EMERGENCY CONTACT NUMBER

Paramedic : 082250318808 HSE Chief HEC : TBA
Doctor : TBA HSE Chief Rekind : Donny 08122771096
HM Advisor : 08115405405 HSE Chief PP : Boby 085649253348

6.3 REPORTING AND INVESTIGATION

Reporting and recording incidents is recognised as an important component in hazard control, risk
management and incident prevention.

Contractor under the regulation is to keep a record of all work-related injuries, illnesses, and
dangerous events. Contractor is also required to have effective processes for investigating
workplace-related incidents and illnesses and for the implementation of corrective and preventive
actions.

All workplace incidents, injuries, illnesses and near misses must be recorded as soon as
possible but no more than within two days of occurring; however notifiable incidents must be
reported immediately after becoming aware of the notifiable incident

Detail please refer Incident Investigation and Reporting Procedure Doc. No. : 26071-100-GPP-
GHX-00019

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Job No.: 26071 Rev.001

Surat Keterangan Berobat

Medical Notification Medical
No. ________________ Provider Logo

To Whom It May Concern

Yang bertandatangan dibawah ini, menerangkan bahwa :

I hereby clarify that :

Nama : Tanggal Lahir / Umur :

Name Birth of Date / Age
…………………………………………………………… ………………………
Alamat : Posisi Pekerjaan :
Address Job position
…………………………………………………………… ………………………

Berdasarkan pemeriksaan medis pada tanggal bahwa ybs. memerlukan ;

Based on medical examination on date ………………………… that he / she need:

1 Pemeriksaan ulang Pada Hari & tanggal

To repeat Medical Examination Day & date ____________ ________________

2 Memerlukan istirahat mulai tanggal ; sampai tanggal

Sick leave starting date _________ Until date _________
Untuk selama duration hari
for ______ (_______________ ) day(s)

3 Dirujuk ke dokter spesialis Di Rumah Sakit

Refer to Specialist __________________________ On Hospital __________

4 Kemungkinan sakit / cedera terkait pekerjaan Note :

Possibility of work related illness / injury Yes / No (*) ___________________________

Balikpapan, ……………………….
Medical Examiner

_________________________

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