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Daily SHE Report Form No.

Rev No.: 00

Indonesia 1 Project Date: 15 Feb 2019

Jakarta Page: Page 1 of 2

Date 15 Februari 2019

Prepared by Budi Apriyansyah
Manpower Attention

Binkei = 72
Subkont = 197
Total = 269
Work permits Attention

Number Weekly work permits valid this week 41 (Binkei = 2 + Subcon = 39)
Number Daily Work permits approved today Binkei =
Subkont =
A. Communication Given Y/N Number/Subject Attention

Safety Induction Y 3 / Aturan K3L

Safety Talk Y 1 / Penggunaan APD
Toolbox Meting Y 1 / Prosedur Kerja
B. Inspection Given Y/N Number Attention

SHE Patrol Y 1
SHE Inspection (General) N
Tools and equipment N
Housekeeping Y 1
C. Simulation/Drill Given Y/N Number Attention

Fire N
Evacuation N
First Aid N
D. Training Given Y/N Number
SHE Orientation/ Induction & Site Safety Y 3
PPE Awareness/ Dasar APD Proyek N
Permit To Work / Perizinan Kerja N
JSA & Risk Assessment N
Basic First Aid/ P3K N
Lock Out Tag Out (LOTO) N
Waste Management/ Manajemen B3 N
Working at Height N
Mechanical & Electrical Safety N
Confined Space/ Ruangan Terbatas N
Driving Safety/ Keselamatan Berkendara N
AK3 Umum / AK3 Migas N
Basic Rigging and Lifting N
Scaffolding N
E. Occupational Health Program Attention

Fogging N
Extra Food / Vitamin N
Donor Darah N
Pemeriksaan Kesehatan Pekerja N
Pemeriksaan Kerja untuk Pekerja N
Beresiko Tinggi
F. Program Reward & Punishment
Reward/ Pengahrgaan N
Punishment N
Daily SHE Report Form No.:

Rev No.: 00

Indonesia 1 Project Date: 15 Feb 2019

Jakarta Page: Page 2 of 2

G. HSE observations Attention

Category Number Comment

1. Procedure
2. Tool and Equipment
3. Mechanical
4. Electricity
5. Plumbing
6. Overhead activity
7. Crane / Lifting
8. Working at heights
9. Scaffolds
10. Gas Cylinders
11. Hot works
12. Environment
13. Chemical
14. Housekeeping 1
15. Excavation
16. Confined spaces
17. PPE
16. Other
Total number of Work stoppage
Total Number of open items
Number of items past deadlines
H. Incidents Attention

Category Number Comment

Near Miss (NM) 0
First Aid Case (FAC) 0
Medical Treatment Case (MTC) 0
Restricted Work Case (RWC) 0
Lost Workdays Case (LWC) 0
Lost Time Injury (LTI) 0
Fatality 0
Property Damage 0
Environment Damage 0
Reputation 0
For more information on the accidents (if applicable) please refer to incident report)

Nr Picture Observations / Close out

Before After required action before
1. Lokasi : B6 19 Feb 2019

Material pipa dan

support yang
berserakan di area

Saran : Segera rapikan

material tersebut dan
taruh ke gudang