INSPECTION

KOTAK P3K DAN OBAT - OBATAN Keselamatan dan Kesehatan Kerja

Periode Bulan / Tahun: Penanggung jawab:

Jumlah item yang ada
No Nama Item Kotak P3K Jumlah Keterangan
Office GN 10 GB 18

1 Kasa steril 20 pcs

2 Perban (lebar 5 Cm) 2 pcs

3 Perban (lebar 10 Cm). 2 pcs

4 Plester (lebar 1,25 Cm). 2 pcs

5 Plester Cepat. 10 pcs

6 Kapas (25 gram). 1 pcs

7 Kain segitiga/mittela. 2 pcs

8 Gunting. 1 pcs

9 Peniti 12 pcs

10 Sarung tangan sekali pakai 2 pcs

11 Masker. 1 pcs

12 Pinset. 1 pcs

13 Lampu senter. 1 pcs

14 Gelas untuk cuci mata. 1 pcs

15 Kantong plastik bersih. 1 pcs

16 Aquades (100 ml lar.Saline) 1 pcs

17 Povidon Iodin (60ml) 1 pcs

18 Alkohol Swab 10 pcs

19 Cairan Pembersih Mata 1 pcs

20 Bioplacenton 1 pcs

21 Thrombopop 1 pcs

Keterangan: pengisiian kolom jumlah item yang ada diisi dengan menggunakan angka
 CHEKLIST APAR CHEKLIST APAR CHEKLIST APAR CHEKLIST APAR
PT. Yerry Primatama Hosindo PT. Yerry Primatama Hosindo PT. Yerry Primatama Hosindo PT. Yerry Primatama Hosindo

No APAR / Lokasi : TAHUN 2013 P. JAWAB: No APAR / Lokasi : TAHUN 2013 P. JAWAB:
Next Refill / Expired : No Bulan Tgl cek Remarks Sign Next Refill / Expired : No Bulan Tgl cek Remarks Sign

1 January 1 January

2 February 2 February

3 March 3 March

APAR 4 April

5 May
APAR 4 April

5 May

SIAP 6 June SIAP 6 June

DIGUNAKAN
( READY TO
7 July

8 August
DIGUNAKAN
( READY TO
7 July

8 August

USE ) 9 September

10 October
USE ) 9 September

10 October

11 November 11 November

12 December 12 December
NOMOR NOMOR
APAR APAR

1 3
PT. Yerry Primatama Hosindo
[ Engineering Division ]

NOMOR
PT. Yerry Primatama Hosindo
[ Engineering Division ]

NOMOR
APAR APAR

2 4
PT. Yerry Primatama Hosindo
[ Engineering Division ]
PT. Yerry Primatama Hosindo
[ Engineering Division ]
OR NOMOR NOMOR
R APAR APAR

OR
5 7
PT. Yerry Primatama Hosindo
[ Engineering Division ]

NOMOR
PT. Yerry Primatama Hosindo
[ Engineering Division ]

NOMOR
R APAR APAR

6 8
PT. Yerry Primatama Hosindo
[ Engineering Division ]
PT. Yerry Primatama Hosindo
[ Engineering Division ]
OR NOMOR NOMOR
R APAR APAR

OR
9 11
PT. Yerry Primatama Hosindo
[ Engineering Division ]

NOMOR
PT. Yerry Primatama Hosindo
[ Engineering Division ]

NOMOR
R APAR APAR

10 12
PT. Yerry Primatama Hosindo
[ Engineering Division ]
PT. Yerry Primatama Hosindo
[ Engineering Division ]
R NOMOR NOMOR
APAR APAR

R
13 15
PT. Yerry Primatama Hosindo
[ Engineering Division ]

NOMOR
PT. Yerry Primatama Hosindo
[ Engineering Division ]

NOMOR
APAR APAR

14 16
PT. Yerry Primatama Hosindo
[ Engineering Division ]
PT. Yerry Primatama Hosindo
[ Engineering Division ]
 FORM INSPEKSI
KOTAK P3K DAN OBAT - OBATAN
Periode Bulan / Tahun: Penanggung jawab:
Jumlah Stok Stok
Jumlah
Standar Office GN 10 GB 18 GD 08
No Nama Item Kotak P3K Standar Keterangan
sesuai
Perusahaan
Regulasi Jumlah Penambahan Jumlah Penambahan Jumlah Penambahan Jumlah Penambahan
1 Kasa steril 40 pcs 5 pcs
2 Perban (lebar 5 Cm) 6 pcs 1 pcs
3 Perban (lebar 10 Cm). 6 pcs 1 pcs
4 Plester (lebar 1,25 Cm). 6 pcs 1 pcs
5 Plester Cepat. 20 pcs 5 pcs
6 Kapas (25 gram). 3 pcs 1 pcs
7 Kain segitiga/mittela. 6 pcs ˗ pcs
8 Gunting. 1 pcs ˗ pcs
9 Peniti 12 pcs ˗ pcs
Sarung tangan sekali
10 4 pcs 1 pcs
pakai
11 Masker. 1 pcs 1 pcs
12 Pinset. 1 pcs ˗ pcs
13 Lampu senter. 1 pcs ˗ pcs
14 Gelas untuk cuci mata. 3 pcs ˗ pcs
15 Kantong plastik bersih. 1 pcs ˗ pcs
Aquades (100 ml
16 lar.Saline) 1 pcs ˗ pcs
17 Povidon Iodin (60ml) 1 pcs 1 pcs
18 Alkohol Swab 1 pack 4 pcs
19 Cairan Pembersih Mata 1 pcs 1 pcs
20 Bioplacenton 1 pcs 1 pcs
21 Rivanol 1 btl 1 pcs
22 Thrombopop 1 pcs 1 pcs
23 Buku Pedoman P3K 1 pcs 1 pcs
Keterangan: pengisiian kolom jumlah item yang ada diisi dengan menggunakan angka
Tanggal Pemeriksaan:
Tanda Tangan :

(HSE Officer)

Form Number : OP-HSE-002-FM002 ( Rev.01)