CONTRACTORS PREQUALIFICATION

HSE QUESTIONNAIRE

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 HSE QUESTIONNAIRE FOR PREQUALIFICATION

FORM 1

Date : 06 juni 2019

_____________________________________________

Name of Contractor : PT. PERSONEL ALIH DAYA (PERSADA) ____________

Tender No. : TAT- DS190009

Supply of Goods/Services : SECURITY SERVICES FOR PALMERAH PSC

Subject : Contractor HSE Pre-qualification Form (PQF)

TATELY N.V. desires to continually improve their HSE performance. The Company recognizes that
vendors and suppliers contribute a large amount to our overall HSE efforts and performance. We
therefore wish to select organizations that have a common goal and similar approach to our business
principles. Only those contractors who demonstrate management leadership and compatible
systems, resulting in good safety and health performance shall be placed on our approved
vendors/service providers list. We therefore request that you complete this HSE screening form and
return it as instructed. Those organizations successfully pass this initial screening process will be
included on COMPANY approved vendor/service provider list.

COMPANY expects that the applicant (Vendor/Service Provider) to:

 Have a documented health and safety program (HSE Management System) that meets
the requirements of the goods or services that you are offering at this screening stage.
 Have a program for implementing the requirements of health and safety program (HSE
Management System)
 Have a commitment to screen and apply these standards to any sub-contractor that
vendor/supplier of services may use.

Please return the Completed form to the address below:

- Contract Service Group - COMPANY
If assistance is needed in completing this form, please contact:

Name : Togap Sinaga / Sulistyo Anjasmoro

Address : COMPANY JAKARTA OFFICE
Phone : 021-2966.0262 ext. 2144 / 2202 or fax 021-2966.0335

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COMPANY hereby reserves the right to inspect and interview any of your personnel with the
purpose of verifying the correctness of your response.

Any misrepresentation of facts will result in rejection / disqualification of the Vendor/Service

Provider from the Tately approved Vendor/Service Supplier List.

Following completion and return of this documentation the submission will be evaluated.
However, marking of the submission will not occur until the data has been verified by a Tately
representative, following which the overall screening will be objectively marked. The passing
mark required for registration as an approved Vendor/Supplier of Services to Tately N.V., is 64
from a possible 100.

Successful Vendors/Supplier of Services will be given a certificate of approval with a validity

period of 2 years.

Unsuccessful Vendors/Supplier of Services will be notified of the deficiencies found in their

HSE Management System and areas requiring improvement. From the date of notification,
unsuccessful Vendors/Supplier of Services will be prohibited from re-applying for a period of 4
calendar months.

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 CONTRACTORS HSE PRE–QUALIFICATION

FORM 2

GENERAL INFORMATION
1. Contractor Name Telephone :

Street address : Mailing address:

2. Officers Name Years With Company

President Ir.SUWIGNYO 2006

Vice President

Treasurer DRA.KOMALANINGSIH

3. How many years has your organization been in business under your present Company name?

4. A. Parent Company name :

State : HEAD OFFICE
City : JAKARTA PERSADA JAKARTA
Zip :
SELATAN Jl.Poltangan raya No.35, Jakarta
Selatan 12530
Subsidiaries :

B. Principal Company name:

State: PERSADA
City: PALEMBANG PALEMBANG Jl.Angkatan 45 Zip :
No.222 Palembang

5. Under Current Management Since (Date):

6. Contact for Requesting Bids :

Title : Telephone : Fax :

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 7. Screening Completed By : *)
*) This Form must be completed and signed by an Authorized Vendor/Supplier of Services Executive
or Senior Manager
Title : Telephone : Fax :

ORGANIZATION
8. Form of Business : Firma/CV Perseroan Terbatas/PT Others

9. List other types of work within the services you normally perform that you subcontract to others:

COMPANY WORK HISTORY

10. Major jobs in progress :*)
*) Use additional paper as necessary

11. Major jobs completed in the past three years :

 PT. INDOSAT
 BANK NEGARA INDONESIA
 DUNIA KIMIA UTAMA
 CHANDRA SAKTI UTAMA LEASING
 PRODIA
 RS. PERTAMEDIKA
 PT. GRAHA INTI MAS
 INDOMOBIL NISSAN
 BFI FINANCE INDONESIA
 ANDALAN FINANCE
 PT. GAPURA ANGKASA
 BANK SYARIAH MANDIRI
 ASTRA CREDIT COMPANIES
 AMINDOWAY
 APLIKASI KARYA ANAK BANGSA
 ASTRA WORLD
 IM2
 MITSUI LEASING
 PUMA ENERGY
 WIDATRA BHAKTI
 MADANI TALATAH NUSANTARA
 BEIERSDORF INDONESIA
 MESTIKA

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Customer/Location Type of Work Size $M Customer Contact Telephone

Pt. Indosat/Sumbagsel Security

Bank Negara Indonesia Security
Pt.Semen
Security
Baturaja/Palembang
Bank Mestika/Palembang Security
Gapura Angkasa/Sumbagsel Security
Bank Bni/Palembang Security
Bfi/Palembang Security
Pt.Csul/Palembang Security
Pt.Dku/Sumbagsel Security
Acc/Palembang Security
Gojek/Sumbagsel Security
Pt. Prodia/Palembang Security
Graha Intimas/Sumbagsel Security
Pt.Wihana Irawan
Security
(Nisan)/Palembang
15. Are there any judgments, claims or suits pending or outstanding against your Company?
If yes, please attach details. Yes No

Contractor Reps: COMPANY HSE:

(Name/Date) (Name/Date)

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Petunjuk pengisian lembar kuesioner K3LL
 Jawablah setiap pertanyaan dengan benar dan jelas sesuai dengan maksud dari setiap
pertanyaan,
 Jawaban hendaknya tidak “terlalu” singkat atau bertele-tele,
 Jika ada pertanyaan yang tidak berhubungan dengan bisnis/pekerjaan/jasa yang
ditawarkan, jangan dikosongkan atau tidak dijawab tetapi jawablah “Tidak Relevan”,
sehingga pertanyaan dimaksud tidak akan mengurangi poin saudara,
 Setiap jawaban agar disertai dengan bukti-bukti pelaksanaan, bukti-bukti dimaksud harus
dilampirkan dan diberi tanda nomer referensi sesuai dengan nomer pertanyaan (contoh
“Lampiran 1a” untuk bukti pendukung untuk pertanyaan 1a, dst)
Hal ini dimaksudkan untuk mempermudah dan mempercepat penilai dalam melakukan
evaluasi,
 Jawaban dengan nilai yang terbaik/tertinggi adalah jawaban yang komprehensif yang
memberikan gambaran yang jelas, tepat, lugas dan disertai dengan bukti-bukti yang
mendukung,

Instruction to fill in the response to the HSE Questionaire

 Answer each question correctly and clearly according to the intent of each question,
 Answers should not be "too" short or long-winded,
 If there are any questions that are not related to the business / job / service offered, do not
leave it empty or not answered but answer "Irrelevant", so the question will not reduce your
points
 All answers should be supported by evidence of implementation that shall be attached and
marked with reference number according to the number of questions (eg "Appendix 1a" ffor
questions 1a, etc.)
This is intended to facilitate and speed up the appraiser evaluation,
 The answer with the best / highest score is a comprehensive answer that provides a clear,
precise, straightforward and backed up by supporting evidence,

Tately N.V./Zaratex N.V. HSE Pre-Qualification Questionnaire Rev.5

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 CONTRACTORS HSE PROGRAM

FORM 3

Date /Tanggal : _____________________________________________

Name of Contractor’s Company : _____________________________________________

Tender No : _____________________________________________

Subject provision : _____________________________________________

SECTION 1: LEADERSHIP AND COMMITMENT BAGIAN 1 : KEPEMIMPINAN DAN

KOMITMEN
1. Commitment to HSE through leadership / 1.1 Komitmen K3LL melalui
kepemimpinan
a) How are Executives/Senior Managers personally involved in HSE
management?
Bagaimana para senior manajer terlibat secara pribadi dalam manajemen K3LL?

b) Does your Organization have a requirement for Senior/Executive Managers to

visit your Field Operations to ensure that your organizations HSE standards are being
applied and maintained?
Apakah organisasi anda mensyaratkan bagi Manejer Senior/Eksekutif untuk melakukan
kunjungan lapangan guna memastikan bahwa standar K3LL diterapkan dan dijaga?

c) How does your organization promote a positive culture towards HSE matters?
Bagaimana Anda mempromosikan budaya yang positif terhadap masalah – masalah K3L

SECTION 2: POLICY AND STRATEGIC OBJECTIVE / BAGIAN 2 : TUJUAN KEBIJAKAN

DAN STRATEGI
2.1 HSE Policy and Documents / 2.1. Kebijakan dan Dokumen K3LL
a) Does your company have an HSE policy document? If yes, please attach
Apakah perusahaan mempunyai dokumen kebijakan K3LL?  Yes  No
Jika Ya, lampirkan.

When was it last reviewed and signed?

Kapan terakhir ditinjau ulang dan di paraf?

b) Who has overall and final responsibility for HSE Management in your organization?
Siapa yang memikul tanggung jawab keseluruhan dan tanggung jawab akhir dari K3LL
dalam organisasi Anda ?

c) Who is the most senior person in the organization responsible for this policy being
implemented where his employees are working?
Siapa orang yang paling senior dalam organisasi yang bertanggung jawab terhadap
kebijakan yang sedang dijalankan pada daerah kewenangan dan lokasi di mana
karyawannya bekerja ?

Tately N.V./Zaratex N.V. HSE Pre-Qualification Questionnaire Rev.5

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2.2 Availability of Policy Statement to employees / 2.2. Tersedianya Pernyataan Kebijakan
bagi Karyawan
a) Itemize the methods by which you have drawn your policy statement to the attention of all your
employees.
Jelaskan secara rinci metoda-metoda yang Anda gunakan sebagai sumber pernyataan
kebijakan kepada semua karyawan Anda.

b) What are your arrangements for advising employees of changes in the policy or any of your
HSE Standards?
Pengaturan apa yang Anda punyai untuk memberitahu karyawan mengenai perubahan-
perubahan kebijakan ?

SECTION 3: ORGANIZATION, RESPONSIBILITY, RESOURCES, STANDARDS

AND DOCUMENTATION / BAGIAN 3 : ORGANISASI, TANGGUNG JAWAB,
SUMBER DAYA, STANDAR DAN DOKUMENTASI
3.1 Organization - Commitment and Communication / 3.1. Organisasi – Komitmen dan
Komunikasi
a) How is management involved in setting and monitoring HSE Goals and Objectives?
Bagaimana keterlibatan manajemen dalam aktivitas-aktivitas K3LL, penetapan tujuan
dan pemantauan ?

b) Do you have a safety organization?  Yes  No.

Apakah Anda punya organisasi keselamatan?.

c) If Yes, please provide an organization chart and a description of responsibilities

Kalau ada, tunjukkan bagan organisasi dan uraian tanggung jawab

d) How Is your company structured to manage and communicate HSE matters effectively?
Bagaimana struktur perusahaan Anda dibuat untuk mengelola dan mengkomunikasikan
K3LL secara efektif

e) What provision does your company make for HSE communication meetings?
Ketentuan apa yang dibuat perusahaan Anda untuk rapat-rapat komunikasi K3LL?

3.2 Competence and Training of Manager/Supervisor/Senior Site Staff/HSE Adviser, 3

Kemampuan dan Pelatihan Manajer/Pengawas/Petugas Senior Lapangan/Penasihat
K3LL
Have the managers and supervisors at all levels that will plan, monitor, oversee and carry out the
work received formal HSE training in their responsibilities with respect to conducting work to HSE
requirements?  Yes  No
Apakah para manajer dan pengawas di semua tingkat yang akan merencanakan,memantau,
memperkirakan dan melaksanakan pekerjaan sudah menerima pelatihan formal K3LL sesuai
tanggung jawab mereka dalam kaitannya dengan pelaksanaan pekerjaan sesuai dengan
persyaratan-persyaratan K3LL ?

If Yes please give details. (Where the training is given in-house please describe the content and
duration of courses, if training is external, please provide name of training provider, course title and
duration of training).
Jika sudah, berikan rincian. Jika pelatihan diberikan in-house, jelaskan materi dan lamanya
kursus

Tately N.V./Zaratex N.V. HSE Pre-Qualification Questionnaire Rev.5

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3.3 Competence and General HSE Training / 3.3. Kemampuan dan Pelatihan K3LL Umum
a) What arrangements does your organization have to ensure employees have knowledge of
basic industrial HSE, and to keep this knowledge up to date?
Pengaturan apa yang telah dibuat perusahaan Anda untuk memastikan bahwa
karyawan mempunyai pengetahuan tentang K3LL dasar dalam industri, dan untuk
menjaga agar pengetahuan tersebut selalu terkini?

b) What arrangements does your company have to ensure new employees, including sub
contractors, have knowledge of your HSE policies and practices?
Pengaturan apa yang telah dibuat perusahaan Anda untuk memastikan bahwa karyawan,
termasuk subkontraktor, juga memahami kebijakan dan tata cara K3LL Anda ?

SECTION 3: ORGANIZATION, RESPONSIBILITY, RESOURCES, STANDARDS

AND DOCUMENTATION / BAGIAN 3 : ORGANISASI, TANGGUNG JAWAB, SUMBER DAYA,
STANDAR DAN DOKUMENTASI
3.4 Competence and General HSE Training (Continued) / 3.3. Kemampuan dan Pelatihan
K3LL Umum
a) What training do you provide to ensure that all employees are generally aware of your company
HSE requirements
Pelatihan apa yang telah Anda berikan untuk memastikan bahwa semua karyawan
mengetahui semua persyaratan-persyaratan perusahaan ?

b) What arrangements does your company have to ensure new employees and new subcontractor
employee have been instructed and have received information regarding the specific hazards
arising out of the their activities on behalf of your organization?
Pengaturan apa yang telah dibuat perusahaan Anda untuk memastikan bahwa
karyawan dan karyawan subkontraktor yang baru telah diberi instruksi dan
menerima informasi mengenai bahaya spesifik yang timbul dari sifat pekerjaan?

c) What arrangements does your company have to ensure the HSE knowledge of existing staff is up
to date? If training is provided in-house please give details of content
Pengaturan apa yang telah dibuat perusahaan Anda untuk memastikanbahwa
pengetahuan K3LL karyawan yang sekarang selalu up to date ? Jika pelatihan
dilakukan in-house berikan rincian materi pelatihan.

3.5 Specialized Training / 3.4. Pelatihan Khusus

a) How have you identified areas of your company's operations where specialized training is
required to mitigate potential hazards? Please itemize and provide details of any such
training.
Bagaimana Anda telah mengidentifikasi lokasi di dalam operasi Anda di mana
pelatihan khusus diperlukan untuk menghadapi bahaya yang mungkin terjadi ?
Berikan daftar dan rincian dari pelatihan yang diberikan.

b) If your work involves specific hazards (i.e. radioactive material handling, asbestos removal,
chemical handling, crane or heavy plant operation etc.) or other occupational health and safety
hazards, how are the hazards identified, assessed and controlled?
Jika suatu pekerjaan khusus melibatkan radioaktif, pembuangan asbes, bahan kimia atau
bahaya kesehatan kerja lainnya, bagaimana bahaya tersebut diidentifikasi, dinilai
dan diatasi ?

Tately N.V./Zaratex N.V. HSE Pre-Qualification Questionnaire Rev.5

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3.6 HSE Qualified Staff – Additional Training / 3.5. Karyawan yang mempunyai
Kemampuan K3LL– Pelatihan Tambahan
a) Does you company employ any staff that possess specialized HSE qualifications that
aim to raise their competence above the basic requirements?  Yes  No
Apakah perusahaan Anda mempekerjakan staf yang memiliki kualifikasi K3LL yang
ditujukan untuk memberikan pelatihan yang lebih dari sekadar persyaratan dasar ?

b) What level of HSE qualification does your HSE staff have? Please describe:
Format kualifikasi keselamatan mana yang dipunyai oleh staf Anda ? Jelaskan

3.7 Assessment of Suitability of Subcontractors / Other Companies, 3.7. Penilaian

mengenai kesesuaian subkontraktor / Perusahaan Lain
a) How do you assess / Bagaimana Anda menilai :

Sub-contractor HSE competence / Kemampuan K3LL:

HSE record of the subcontractors and companies with whom you place contracts? / Catatan K3LL
subkontraktor dan perusahaan-perusahaan yang Anda kontrak ?

b) Where do you spell out the standards you require your contractors to meet?
Di mana Anda menjelaskan standar yang dituntut agar dipenuhi oleh kontraktor Anda ?

SECTION 3: ORGANIZATION, RESPONSIBILITY, RESOURCES, STANDARDS

AND DOCUMENTATION / BAGIAN 3 : ORGANISASI, TANGGUNG JAWAB, SUMBER DAYA,
STANDAR DAN DOKUMENTASI
c) How do you ensure these standards are consistently met and verified?
Bagaimana Anda memastikan standar-standar di bawah ini telah dipenuhi dan diperiksa ?

d) Please provide the names and scope of work of major sub-contractors you regularly use:
Tolong disediakan nama-nama subkontraktor utama, pada saat ini, kalau diketahui.

3.8 Standards / 3.7. Standar

a) Where do you spell out the HSE performance standards you require to be met?
Dimana anda menyatakan standar kinerja K3LL yang perlu dicapai?

b) How do you verify that these are consistently met?

Bagaimana cara Anda memastikan bahwa standar K3LL tersebut dilaksanakan ?

c) How do you identify new industry or regulatory standards that may be applicable to your
activities?
Bagaimana Anda mengetahui standar-standar industri dan aturan baru K3LL yang mungkin
berlaku bagi aktivitas Anda ?

d) Is there an overall system for producing, updating and controlling HSE documentation within
your organisation?
Adakah struktur menyeluruh untuk membuat, memperbarui dan mengendalikan standarK3LL ?

e) List the index of your HSE procedures manuals. Please submit current copies
Jelaskan isi dari manual prosedur K3LL. Sertakan salinan terbaru

Tately N.V./Zaratex N.V. HSE Pre-Qualification Questionnaire Rev.5

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SECTION 4: HAZARDS AND EFFECT MANAGEMENT / BAGIAN 4 : PENANGANAN
BAHAYA DAN DAMPAK
4.1 Hazards and Effect Management / 4.1.Penanganan Bahaya dan Pengaruh
a) What techniques are used within your company for the identification, assessment, control and
mitigation of hazards and effects?
Teknik apa yang Anda gunakan dalam perusahaan Anda untuk mengidentifikasi, menilai,
mengawasi dan mengurangi bahaya dan dampak ?

4.2 Exposures of the Workforce / 4.2.Paparan terhadap Pekerja

a) What systems are in place to monitor the exposure of your workforce to any identified
occupational health hazards?
Sistem apa yang ada untuk memantau paparan pekerja Anda terhadap bahan kimia atau
unsur-unsur fisik ?

4.3 Handling of Potential Hazards / 4.3.Penanganan Bahaya yang Potensial

a) How do you ensure that mitigation measures required to reduce the effects of health and
safety hazards of your staff and contractors are implemented during the course of their work?
Bagaimana Anda memastikan bahwa tindakan pencegahan yang dibutuhkan untuk
mengurangi dampak tersebut dilakukan oleh baik karyawan anda maupun kontraktor saat
mereka bekerja ?

4.4 Personnel Protective Equipment / 4.4.Alat Pelindung Diri

a) What arrangements does your company have for provision and unkeep of protective
equipment and clothing, both standard issue, and that required for specialized activities?
Pengaturan apa yang dipunyai perusahaan Anda untuk pengadaan dan pemberian protective
equipment dan pakaian kerja, baik yang standar maupun yang diperlukan untuk
kegiatan-kegiatan khusus ?

b) Do you provide Personal Protective Equipment (PPE) that is manufactured to a specified

international standard to your employees? Please provide a listing of the PPE standards that
you apply.
Apakah Anda menyediakan Alat Pelindung Diri / Personnel
Protective Equipment (APD/PPE) yang sesuai untuk karyawan Anda ? Berikan daftar
APD/PPE untuk lingkup kerja ini.

c) Do you provide training on how to use PPE? Explain the content of the training and any
follow-up!
Apakah Anda memberikan pelatihan mengenai cara menggunakan APD/PPE ?
Jelaskan materi pelatihan dan setiap tindak lanjutnya.

d) Do you have a program to ensure that PPE is inspected and maintained?

Apakah Anda mempunyai program untuk memastikan bahwa APD/PPE digunakan
dan dijaga ?

4.5 Waste Management / 4.5. Penanganan Limbah

a) What systems do you have in place for identification, classification, minimization and
management of waste?
Sistem apa yang ada untuk identifikasi, klasifikasi, pengurangan dan penanganan limbah?

b) Please provide the number of accidents resulting in environmental damage in amounts

greater than USD 5,000 for the last 24 months. Attach copies of any government reports
submitted

Tately N.V./Zaratex N.V. HSE Pre-Qualification Questionnaire Rev.5

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 Berikan jumlah kecelakaan yang menyebabkan kerusakan lingkungan dalam jumlah
yang melebihi USD$ 50,000 untuk 24 bulan terakhir Lampirkan copy laporan yang
dikirim kepemerintah.

c) Do you have procedures for waste disposal?  Yes  No

Apakah Anda mempunyai prosedur untuk pembuangan limbah ? Ya Tidak

d) Do you have hazardous temporary storage completed with waste balance and permit?
e)  Yes  No
If Yes, please be attached the copy of waste balance and permit.
Apakah Anda mempunya tempat penyimpanan sementara (gudang) limbah bahan berbahaya
dan beracun/LB3 yang dilengkapi neraca limbah dan berizin?
Jika Iya, agar dilampirkan kopi neraca limbah dan izinya.

f) Do you have a contract with third party for handling the hazardous waste?  Yes  No
If Yes, please be attached the copy of the contract and manifest.
Apakah Anda mempunya kontrak untuk mengelola limbah B3?
Jika Iya, agar dilampirkan kopi kontraknya dan manifest limbahnya.

g) Do you have procedures for spill reporting?  Yes  No

Apakah Anda mempunyai prosedur untuk melaporkan tumpahan minyak dan / atau bahan
berbahaya lainnya ?

h) Do you have procedures for spill clean up?  Yes  No

Apakah Anda mempunyai prosedur untuk pembersihan tumpahan minyak dan / atau bahan
berbahaya lainnya ?

i) Please provide details at any of your equipment related to environmental matters

Berikan rincian mengenai peralatan Anda yang berkaitan dengan masalah lingkungan.

j) Who is the person in charge for coordinating environmental management matters and provide
details of their experience?
Siapa orang yang berwenang untuk mengkoordinasikan masalah lingkungan dan bagaimana
dengan pengalamannya ?

4.6 Industrial Hygiene / 4.6. Kesehatan Industri

a) Do you have an industrial hygiene program?  Yes  No
If so, what does it include?
Apakah Anda mempunyai program kesehatan industri ? Ya Tidak
Kalau ada, apa saja yang termasuk di dalamnya ?

b) Do you have a risk assessment, or similar type effort, for identifying work place health
hazards? Please describe this process
Apakah Anda mempunyai penilaian risiko, atau usaha serupa, untuk mengidentifikasi bahaya
di tempat kerja? Jelaskan proses ini.

c) If you introduce hazardous materials/substances into the work site, describe the process you
will use to assess the hazards and control the effects of these?
Jika Anda mendatangkan bahan / zat berbahaya ke tempat kerja, jelaskan proses yang akan
Anda gunakan untuk mendokumentasikan dan mengawasinya.

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4.7 Drugs and Alcohol / 4.7 Obat-Obatan dan Alkohol
a) Do you have a drugs and alcohol policy in your organization? If so, please describe how this
is implemented.
Apakah organisasi anda memiliki kebijakan tentang obat-batan dan alcohol? Jika Ya, mohon
dijelaskan bagaimana penerapannya.

SECTION 5: PLANNING AND PROCEDURES / BAGIAN 5: PERENCANAAN DAN

PROSEDUR
5.1 HSE or Operations Manuals / 5.1. Buku panduan K3LL dan Operasi
a) Do you have a company HSE manual or Operations Manual with relevant sections on HSE
which describes in detail your company approved HSE working practices and safety
instructions for your organization’s activities?  Yes  No
Apakah perusahaan anda memiliki Manual K3LL atau Manual Operasi dengan Bagian K3LL
yang menjelaskan dengan rinci mengenai Kode Bekerja K3LL dan Arahan Keselamatan
untuk aktivitas organisasi?

b) If the answer is Yes, please attach a copy of the supporting documentation (ToC)
Jika jawabannya Ya, lampirkan copy dari dokumen pendukung (Daftar Isi)

c) How do you ensure that the working practices and procedures used by your employees on-
site are consistently in accordance with your written procedures and general HSE
Management arrangements?
Bagaimana Anda memastikan bahwa cara kerja dan prosedur yang digunakan oleh karyawan d
i
lapangan konsisten dengan prosedur tertulis dan pengaturan kebijakan K3LL Anda ?

5.2 Equipment Control and Maintenance / 5.2. Pengawasan dan Perawatan Peralatan
a) How do you ensure that plant and equipment used within your premises, on-site, or at other
locations and used by your employees are correctly registered and certified with the
appropriate regulatory body and inspected, controlled and maintained in safe working
condition?
Bagaimana Anda memastikan bahwa stasiun produksi dan peralatan yang digunakan
di wilayah kerja Anda, lokasi, atau pada lokasi lain oleh karyawan Anda, didaftarkan,
disertifikasi sesuai tuntutan peraturan, diinspeksi, diawasi dan dirawat dengan benar
dan dalam kondisi kerja yang baik ?

5.3 Transport Safety Management and Maintenance / 5.3. Penanganan dan Perawatan
Keselamatan Transportasi
a) What arrangement does your company have for vehicle incident prevention?
Pengaturan apa yang dipunyai perusahaan Anda untuk pencegahan kecelakaan kendaraan ?

SECTION 6: IMPLEMENTATION AND PERFORMANCE MONITORING / BAGIAN 6 :

PEMANTAUAN IMPLEMENTASI DAN KINERJA
6.1 HSE Management and Performance Monitoring of Work Activities / 6.1.
Manajemen K3LL dan pemantauan Kinerja dalam Aktivitas Kerja
a) What arrangement(s) does your company have for supervision and monitoring of HSE
performance?
Pegaturan apa yang dipunyai perusahaan Anda untuk pengawasan dan pemantauan
kinerja K3LL ?

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b) What type of performance criteria are used in your company? Please give examples:
Kriteria kinerja seperti apa yang digunakan dalam perusahaan Anda; berikan contoh

c) What arrangements does your company have for passing on any results and findings of
HSE Inspections and Audits to / Pengaturan apa yang dipunyai perusahaan Anda untuk
menyampaikan setiap hasil dan temuan Inspeksi dan audit K3LL:
i) Executive/Senior Management? / Manajemen pusat Anda ?

ii) Site Supervision and employees? / Karyawan lapangan ?

d) Has your company received any award for HSE performance achievement?
 Yes  No
If yes, please detail the awarding Company or Organization
Pernahkan perusahaan Anda menerima penghargaan untuk prestasi kinerja K3LL ?
Jika Ya, berikan rincian dari perusahaan atau organisasi pemberi

6.2 Safety Program Communication / 6.2. Program Keselamatan

a) Do you organize in-house safety meetings?  Yes  No
Please describe the frequency, attendance and typical topics discussed:
Apakah Anda menyelenggarakan safety meeting di tempat Anda sendiri ?
Jelaskan frekuensi, peserta dan topiknya.

b) Do you organize campaigns to stimulate safe working practices?  Yes  No

If so, please give details:
Apakah Anda mengorganisasikan kampanye untuk menstimulasi cara kerja yang aman ?
Kalau iya, berikan rincian

6.3 Statutory Notifiable Incidents/Dangerous Occurrences, Improvement Requirement

and Prohibition Notices / 6.3. Insiden /Kejadian berbahaya, Tuntutan Perbaikan,
dan Pemberitahuan Larangan yang bersifat Hukum
a) Has your company suffered any improvement requirement or prohibition notices for
infringement of HSE or Employment laws or regulations by MIGAS or DEPNAKER, in the
last five years?  Yes  No

Pernahkan perusahaan Anda mengalami keharusan perbaikan atau pemberitahuan

larangan dalam hal insiden/kejadian berbahaya yang bersifat hukum oleh badan
nasional yang relevan, badan yangberwenang dalam K3LL, atau otoritas penegak
hukum lainnya atau diperkarakan di bawah undang-undang K3LL selama lima tahun
terakhir ini ? Ya Tidak

If your answer is Yes please give details:

Jika jawaban Ya, berikan rinciannya.

6.4 HSE Performance Records / 6.4. Catatan Kinerja K3LL

a) Have you maintained records of your incidents and HSE performance for the last five
years?  Yes  No If Yes, please provide the following:
• Number of Fatalities • Restricted Work Day Cases
• Lost Time Injury Frequency • Fatal Accident Rate
• Lost Workday Cases • Lost Time Injuries Frequency
• Medical Treatment Cases • Total Recordable Incident Rate for each
year

Apakah Anda menyimpan catatan mengenai insiden dan kinerja K3LL Anda untuk lima tahun
terakhir ? Ya Tidak

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Jika Ya, berikan yang berikut ini :
 Jumlah korban Restricted Work Day Cases
 Lost Time Injuries Fatal Accident Rate
 Kasus kehilanganHari Kerja Lost Time Injury Frequency
 Kasus Tindakan Medis Total Recordable Incident Rate for each year

Please include your company definitions of the above mentioned terms:

Sertakan definisi perusahaan Anda mengenai istilah-istilah di atas dalam lembaran terpisah.

b) How is health performance recorded?

Bagaimana kinerja kesehatan didokumentasikan ?

c) How is environmental performance recorded?

Bagaimana kinerja lingkungan didokumentasikan ?

d) How often is HSE performance reviewed? By whom?

Setiap berapa lama kinerja K3LL Anda ditinjau ? oleh siapa ?

6.5 Incident Investigation and Reporting / 6.5. Investigasi dan Pelaporan Insiden

a) Do you have a procedure for the investigation, reporting and follow-up of accidents,
dangerous occurrences or occupational illnesses?  Yes  No
If Yes please attach details.

Apakah Anda mempunyai prosedur untuk investigasi, pelaporan, dan tindak lanjut insiden,
kejadian berbahaya, atau penyakit di tempat kerja ? Ya Tidak
Kalau Ya lampirkan.

b) How are the findings following an investigation, or a relevant incident followed up to ensure
corrective actions are implemented? /
Bagimana temuan setelah investigasi, atau insiden yang relevan ditindaklanjuti unutk
memastikan tindakan perbaikan telah diterapkan?

c) Is the learning from Near Miss HSE reports distributed throughout your organization?
 Yes  No
If yes, please provide an example.
Apakah pelajaran keselamatan dari kejadian Nyaris(near miss) dilaporkan ?
Ya Tidak

d) Please provide the format you use for a) Incident Reporting, b) Incident Investigation and
Follow-up.
Sediakan salinan dari format laporan yang digunakan untuk a) Laporan Kejadian, b)
Laporan Penyelidikan dan Tindak lanjut.

SECTION 7: AUDIT AND REVIEW / BAGIAN 7 : AUDIT DAN PENINJAUAN

a) Do you have written standards for HSE auditing?  Yes  No

Apakah Anda mempunyai kebijakan tertulis mengenai audit K3LL ? Ya Tidak

b) Do these standards for HSE auditing, including unsafe act auditing and the qualifications
of auditors? /

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 Bagaimana kebijakan tersebut menjelaskan standar audit, termasuk audit mengenai tinda
kan yang tidak aman dan kualifikasi untuk auditor ?

c) Does your company develop an annual HSE Plan? Are HSE Audits and inspections
scheduled in this Plan?  Yes  No
Apakah Rencana K3LL perusahaan Anda menyertakan jadwal audit ?Ya Tidak

What range of auditing is covered? / Bidang auditing mana yang dicakup ?

d) How does your management follow up on HSE Audits?

Bagaimana manajemen menindaklanjuti hasil audit ?

SECTION 8: EMERGENCY RESPONSE PROCEDURES / BAGIAN 8 : PROSEDUR

TANGGAP DARURAT
a) Do you have a Company an emergency response plan? / Apakah Anda mempunyai
rencana tanggap darurat  Yes  No
Describe how emergency preparedness is maintained within your organization / Jelaskan
bagaimana kesiapan darurat dijaga dan bagaimana struktur komando dalam keadaan
darurat.

SECTION 9: HSE MANAGEMENT – ADDITIONAL FEATURES / BAGIAN 9 :

MANAJEMEN K3LL - CIRI TAMBAHAN

a) Describe the nature and extent of your company's participation in any relevant industry,
trade, and governmental organizations? / Jelaskan sifat dan sejauh mana partisipasi
perusahaan Anda dalam organisasi yang relevan dengan industri, perdagangan, dan
pemerintahan.

b) Does your company have any other HSE features or arrangements not described
elsewhere in your response to the questionnaire? / Apakah perusahaan Anda mempunyai
ciri atau aturan K3LL lain yang tidak dicantumkan di dalam tanggapan Anda terhadap
kuesioner

c) Please provide the details of any significant HSE achievements or awards.

Mohon sertakan rincian dari pencapaian atau penghargaan bidang K3LL yang pernah
diperoleh?

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