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  • Form Izin Kerja K3

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    Srie Wirawan
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    This document is a high risk work permission form from Meiji Food Indonesia. It requests permission for a specified high risk work activity and provides details about the work, location, supervisor, safety equipment, potential hazards, and safety steps. The form must be prepared by the applicant, checked by the safety officer, approved by the supervisor and manager before the high risk work can commence. It aims to ensure all safety precautions are in place for the protection of workers.

    Originalbeschreibung:

    contoh form izin kerja dengan resiko tinggi

    Originaltitel

    Form-Izin-Kerja-K3

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    This document is a high risk work permission form from Meiji Food Indonesia. It requests permission for a specified high risk work activity and provides details about the work, location, supervisor, safety equipment, potential hazards, and safety steps. The form must be prepared by the applicant, checked by the safety officer, approved by the supervisor and manager before the high risk work can commence. It aims to ensure all safety precautions are in place for the protection of workers.

    Copyright:

    © All Rights Reserved
    Als DOC, PDF, TXT herunterladen oder online auf Scribd lesen
    Markieren Sie unangemessene Inhalte
    921 Ansichten1 Seite

    Form Izin Kerja K3

    Hochgeladen von

    Srie Wirawan
    This document is a high risk work permission form from Meiji Food Indonesia. It requests permission for a specified high risk work activity and provides details about the work, location, supervisor, safety equipment, potential hazards, and safety steps. The form must be prepared by the applicant, checked by the safety officer, approved by the supervisor and manager before the high risk work can commence. It aims to ensure all safety precautions are in place for the protection of workers.

    Copyright:

    © All Rights Reserved
    Als DOC, PDF, TXT herunterladen oder online auf Scribd lesen
    Markieren Sie unangemessene Inhalte
    von 1

    No.

    Dok :
    SURAT IZIN PEKERJAAN RESIKO TINGGI No. Revisi :
    Tgl Rilis :
    MEIJI FOOD INDONESIA HIGH RISK WORK PERMISSION Hal :

    Nomor : Tanggal/Date :

    KLASIFIKASI PEKERJAAN/WORK CLASSIFICATION

    Kerja Panas Kerja Listrik Ketinggian Galian Tanki Ruang Terbatas Plafon Dibawah Lif
    Hot Work Electrically Work at height Excavation Tank Confined Space Ceiling Under Lif

    INFORMASI PEKERJAAN/WORK INFORMATION

    Pekerjaan/Work :
    Lokasi Kerja/Work Location :
    Area :
    Department :
    Nama Pemohon/Name of Applicant :
    Nomor Kontak Pemohon/Contact Number of Applicant :
    Nama Pimpinan Area/Name of Area Leaders :
    Nomor Kontak Pimpinan Area/Contact Number of Area Leaders :
    Nama Pengawas/Supervisor :
    Nomor Kontak Pengawas/Contact Number of Supervisor :
    Petugas K3/Safety Officer :
    Nomor Kontak Petugas K3/Contact Number of Safety Officer :
    PERLENGKAPAN KERJA/WORK EQUIPMENT
    ALAT/EQUIPMENT JML/QTY MESIN/MACHINE JML/QTY MATERIAL JML/QTY

    *Semua perlengkapan kerja diperiksa oleh petugas K3/Every work equipment checked by safety officer

    KESELAMATAN KERJA/WORK SAFETY


    No. AKTIVITAS/ACTIVITY POTENSI BAHAYA/POTENTIAL HAZARD LANGKAH AMAN PEKERJAAN/SAFE WORK STEPS

    PERALATAN KESELAMATAN/SAFETY EQUIPMENT


    Alat Pelindung Diri/Personal Protective Equipment Perlengkapan Keselamatan & Darurat/Safety Equipment & Emergency

    [ ] Helm/Helmet [ ] Sarung Tangan Karet/Rubber Gloves [ ] Pemadam Api (APAR, Karung Goni Basah)/ Fire Extinguisher
    [ ] Kacamata/Glasses [ ] Sarung Tangan Kulit/Leather Gloves [ ] Barikade (Garis Tanda Bahaya)/Warning Danger Line
    [ ] Goggle [ ] Sarung Tangan Las/Welding Gloves [ ] Rambu/Tanda Keselamatan/Safety Sign
    [ ] Tameng Muka/Face Shield [ ] Sabuk Keselamatan/Safety Belt [ ] LOTO (Log Out Take Out)
    [ ] Kap Las/Welding Cup [ ] Full Body Harness [ ] Radio Telekomunikasi/Telecommunication Device
    [ ] Masker Kain/Cloth Mask [ ] Sepatu Keselamatan/Safety Shoes [ ] Jaring/Tali Keselamatan/Safety Rope
    [ ] Masker Kimia/Checmical Mask [ ] Sepatu Boots/Boots [ ] Lainnya/Others :
    [ ] Earplug [ ] Tabung Pernafasan/Respiratory Tube
    [ ] Earmuf [ ] Apron
    [ ] Sarung Tangan Katun/Cotton Gloves [ ] Lainnya/Others :

    VALIDASI IZIN KERJA/WORK PERMISSION VALIDATION


    Disiapkan Oleh/Prepared By Diperiksa Oleh/Checked By Diketahui Oleh/Known By Disetujui Oleh/Approved By
    Pemohon/Applicant Petugas K3/Safety Officer Supervisor Manager
    Nama/Name : Nama/Name : Nama/Name : Nama/Name :
    TTD/Signature : TTD/Signature : TTD/Signature : TTD/Signature :

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