REPORT SHEET (BUKTI HASIL OBSERVASI) UNTUK BUKTI LANGSUNG

FR-PA-06

Perangkat asesmen: TEKNISI RUANG TERBATAS (CONFINED SPACE)

Nama Asesi:

Nama Asesor:

Unit kompetensi:
1. Menerapkan Peraturan Perundang-undangan yang Berlaku dalam Pekerjaan di Ruang
Terbatas
2. Memberi Kontribusi dalam Pembuatan Analisis Keselamatan Pekerjaan (Job Safety
Analysis) JSA) di Ruang Terbatas
3. Menggunakan Alat Pelindung Diri (APD) sesuai Prosedur
4. Melaksanakan Pekerjaan Isolasi Energi (Lock Out Tag Out : LOTO)
5. Memasang Sistem Ventilasi sesuai dengan Kebutuhan di Ruang Terbatas
6. Membuat Penilaian Perubahan Kondisi Kerja yang Harus Diperhitungkan untuk
Kelangsungan Meneruskan Pekerjaan
7. Melakukan Prosedur Komunikasi dengan Rekan Kerja Terkait
8. Memberikan Kontribusi dalam Pembuatan Izin Kerja (Work Permit)
9. Melaksanakan Pekerjaan di Ruang Terbatas sesuai Prosedur
10. Melaksanakan Prosedur Kerja Selamat di Ruang Terbatas
11. Menggunakan Alat Pemadam Api Ringan (APAR) yang Sesuai Kebutuhan di Ruang
Terbatas
12. Melakukan Pertolongan Pertama pada Kecelakaan (P3K)
13. Melakukan Tindakan Tanggap Darurat
Kualifikasi: Teknisi

Tanggal:
Setiap pertanyaan harus terkait dengan elemen/KUK

Petunjuk :
1. Buatlah laporan melaksanakan pekerjaan sebagai Teknisi Ruang Terbatas (Confined Space)
sesuai dengan unit elemen dan KUK di dalam SKKNI pada lembar berikut!
2. Apabila bukti tersebut diatas sudah terdapat pada laporan yang sudah ada maka bisa disi
“nama dokumen bukti hasil pekerjaannya” pada setiap unit SKKNI
 Kode Unit KKK.RT01.001.01
1 Unit Kompetensi Menerapkan Peraturan Perundang-undangan yang Berlaku dalam Pekerjaan di Ruang
Terbatas

Bukti Hasil Pekerjaan Menerapkan Peraturan Perundang-undangan yang Berlaku dalam Pekerjaan di
Ruang Terbatas :
PROSEDUR KERJA DI RUANG TERBATAS (menyusul …. ?)
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
Kode Unit KKK.RT01.002.01
2 Unit Kompetensi Memberi Kontribusi dalam Pembuatan Analisis Keselamatan Pekerjaan (Job Safety
Analysis) JSA) di Ruang Terbatas

Bukti Hasil Pekerjaan Memberi Kontribusi dalam Pembuatan Analisis Keselamatan Pekerjaan (Job Safety
Analysis) JSA) di Ruang Terbatas:
JOB SAFETY ANALYSIS DI RUANG TERBATAS /JSA (terlampir)
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
Kode Unit KKK.RT01.003.01
3 Unit Kompetensi Menggunakan Alat Pelindung Diri (APD) sesuai Prosedur

Bukti Hasil Pekerjaan Menggunakan Alat Pelindung Diri (APD) sesuai Prosedur:
INSPEKSI APD KERJA DI RUANG TERBATAS (terlampir)
PROSEDUR APD (Menyusul …?)
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................

Teknisi Ruang Terbatas (Confined Space) ASSESSMENT TOOLS 1

 Kode Unit KKK.RT02.001.01
4 Unit Kompetensi Melaksanakan Pekerjaan Isolasi Energi (Lock Out Tag Out : LOTO)

Bukti Hasil Pekerjaan Melaksanakan Pekerjaan Isolasi Energi (Lock Out Tag Out : LOTO) :
IDENTIFIKASI SUMBER ENERGI / LOTO (terlampir)
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
Kode Unit KKK.RT02.002.01
5 Unit Kompetensi Memasang Sistem Ventilasi sesuai dengan Kebutuhan di Ruang Terbatas

Bukti Hasil Pekerjaan Memasang Sistem Ventilasi sesuai dengan Kebutuhan di Ruang Terbatas :
HASIL GAS TESTER (terlampir)
SOP PEMASANGAN INSTALASI (menyusul …?
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................

Kode Unit KKK.RT02.003.01

6 Unit Kompetensi Membuat Penilaian Perubahan Kondisi Kerja yang Harus Diperhitungkan untuk
Kelangsungan Meneruskan Pekerjaan

Bukti Hasil Pekerjaan Membuat Penilaian Perubahan Kondisi Kerja yang Harus Diperhitungkan untuk
Kelangsungan Meneruskan Pekerjaan:
SOP PENGENDALIAN & EVALUASI (menyusul..?)
Specific Emergency Response Plan/ERP (terlampir)
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................

Teknisi Ruang Terbatas (Confined Space) ASSESSMENT TOOLS 2

 Kode Unit KKK.RT02.004.01
7 Unit Kompetensi Melakukan Prosedur Komunikasi dengan Rekan Kerja Terkait

Bukti Hasil Pekerjaan Melakukan Prosedur Komunikasi dengan Rekan Kerja Terkait:
Toolbox Meeting (terlampir)
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
Kode Unit KKK.RT02.005.01
8 Unit Kompetensi Memberikan Kontribusi dalam Pembuatan Izin Kerja (Work Permit)

Bukti Hasil Pekerjaan Memberikan Kontribusi dalam Pembuatan Izin Kerja (Work Permit) :
FORM PERMIT TO WORK RUANG TERBATAS (terlampir)
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
Kode Unit KKK.RT02.006.01
9 Unit Kompetensi Melaksanakan Pekerjaan di Ruang Terbatas sesuai Prosedur

Bukti Hasil Pekerjaan Melaksanakan Pekerjaan di Ruang Terbatas sesuai Prosedur:

Tools Checklist (terlampir), Toolbox Meeting (terlampir)
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................

Teknisi Ruang Terbatas (Confined Space) ASSESSMENT TOOLS 3

 Kode Unit KKK.RT02.007.01
10 Unit Kompetensi Melaksanakan Prosedur Kerja Selamat di Ruang Terbatas

Bukti Hasil Pekerjaan Melaksanakan Prosedur Kerja Selamat di Ruang Terbatas:

Toolbox Meeting (terlampir)
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
Kode Unit KKK.RT03.001.01
11 Unit Kompetensi Menggunakan Alat Pemadam Api Ringan (APAR) yang Sesuai Kebutuhan di Ruang
Terbatas

Bukti Hasil Pekerjaan Menggunakan Alat Pemadam Api Ringan (APAR) yang Sesuai Kebutuhan di Ruang
Terbatas:

SOP ALAT PEMADAM KEBAKARAN (menyusul…?)

........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
Kode Unit KKK.RT03.002.01
12 Unit Kompetensi Melakukan Pertolongan Pertama pada Kecelakaan (P3K)

Bukti Hasil Pekerjaan Melakukan Pertolongan Pertama pada Kecelakaan (P3K):

SOP P3K (menyusul ..?)
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................

Teknisi Ruang Terbatas (Confined Space) ASSESSMENT TOOLS 4

 Kode Unit KKK.RT03.003.01
13 Unit Kompetensi Melakukan Tindakan Tanggap Darurat

Bukti Hasil Pekerjaan Melakukan Tindakan Tanggap Darurat:

Emergency Respons Plan/EMR (terlampir)
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................
........................................................... ........................................................... ...........................

Gresik, 07 Juli 2020

Dibuat Oleh, Diperiksa oleh,

(................................................) (....................................................)

Teknisi Ruang Terbatas (Confined Space) ASSESSMENT TOOLS 5