Lampiran 9 :

DEPARTEMEN KESEHATAN R.I HSK-

KANTOR KESEHATAN PELABUHAN KELAS.1 TANJUNG PRIOK
Jalan Raya Pelabuhan No.17 Tipl: 43931045 Fax : 4373267

Dasar Hukum : UU.No.1 tahun 1962 , UU.23 tahun 1992, IHR -1969, UU.No.4 tahun 1984

HASIL PEMERIKSAAN HYGIENE SANITASI KAPAL

Result Of Inspection of Hygiene Sanitary Ship
NO :

1 NAMA KAPAL/ Ship Name :

2 BENDERA / Nationality :
3 ISI KOTOR (M3)/ Gross Volume :
4 NAMA PEMILIK / Owners/Agent :
5 DATANG DARI / Last Port Of Call :
6 TANGGAL/JAM TIBA/ Date / Hour : /
7 DIPERIKSA TGL /JAM / Inspection on : /
8 TEMPAT PERIKSA / Kade :
9 JENIS KAPAL / Ship Type :
10 JUMLAH ABK/PENUMPANG /Total Crew/Passanger : /

NO VARIABEL BOBOT/Max NILAI/ Value SCORE SARAN/ Suggestion/ACTION

1 DEK / Deck 3 1,2,3,4,5,6,7,8,9,10

2 KAMAR ABK/PENUMPANG
5 1,2,3,4,5,6,7,8,9,10
Quarter Crew /Passangers
3 KAMAR MANDI/WC 5 1,2,3,4,5,6,7,8,9,10
Bathroom/Lavatory

4 DAPUR / Galley 10 1,2,3,4,5,6,7,8,9,10

5 GUDANG MAKANAN
5 1,2,3,4,5,6,7,8,9,10
Provisition Storeroom
6 VECTOR 10 1,2,3,4,5,6,7,8,9,10
7 JURU MASAK/ KOKI 10 1,2,3,4,5,6,7,8,9,10
Foor Handlers
8 PERSEDIAAN AIR BERSIH 10 1,2,3,4,5,6,7,8,9,10
Clean Water Supply
9 PERSEDIAAN AIR MINUM
10 1,2,3,4,5,6,7,8,9,10
Drinking Water/Fresh Water
10 PERSEDIAAN MAKMIN 10 1,2,3,4,5,6,7,8,9,10
Food and beverage Supply
11 TEMPAT PENYAJIAN MAKANAN 2 1,2,3,4,5,6,7,8,9,10
Place of Food Presentation
12 TEMPAT SAMPAH/Garbage 7 1,2,3,4,5,6,7,8,9,10
13 SPAL / Sewage 5 1,2,3,4,5,6,7,8,9,10
14 BALLAST TANK 3 1,2,3,4,5,6,7,8,9,10
15 FACILITY SANITARY 5 1,2,3,4,5,6,7,8,9,10

TOTAL BOBOT 100 TOTAL SCORE

KESIMPULAN/Quality Level : BAIK (Good ) / TIDAK BAIK (Ugly )

Pejabat Kesehatan Pelabuhan Nakhoda/Perwira Jaga Pemeriksa/Inspector

Port Health Officer Master/Officer

( ……………………………………) (……………………………. ) (……………………… )

Keterangan/Remarks : 0 - 699 (Ugly ) / 700 - 1000 ( Good )

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