PT.

ELNUSA FABRIKASI KONSTRUKSI

DATA PERSONIL
PERSONIL DATA SHEET

(HARAP DITULIS DENGAN HURUF CETAK)

(PLEASE PRINT)

Nama Perusahaan
Name Company

Nama Panggilan Kewarganegaraan

Nickname Nationality

Jenis Kelamin Umur No. KTP / SIM / dll *)

Sex Age #ID

Nomor telepon yang dapat dihubungi saat darurat

Emergency contact number

Golongan Darah
Blood type

Maksud kedatangan
Aim of visit

Kondisi medis personel ybs yang perlu di-infokan (termasuk alergi)

Personil's medical condition that need to be informed (including allergy)

Saran-saran
Suggestion

Saya sudah membaca dan memahami Formulir Induksi ini, seperti yang telah ditunjukkan dan dijelaskan kepada
saya, dan saya akan mematuhi semua yang disyaratkan dalam Formulir Induksi tersebut.
I have read and understood the induction form as shown and explained to me, and I will be comply for all aspect as mentioned in these induction
form

Tanda Tangan Personil ybs Tanda Tangan Petugas Induksi

Signature Signature of person who giving induction

Tanggal Tanggal
Date Date
Form-SOP-HSE003-02 Rev.1 Effective Date, 10-Sep-2019
 PT. SINAR ECO TECHNOLOGY INDONESIA

INDUKSI K3LL
HSE INDUCTION

Nama :
Name

Perusahaan :
Company

I confirm that I have had the following explained and shown to me:

A. STANDAR KEBIJAKAN K3LL / HSE POLICY STANDARDS

1 Kebijakan PT. Elnusa Fabrikasi Konstruksi ( EFK ) K3LL (diterangkan)
QHSE.Elnusa Fabrikasi Konstruksi Company Policy (explained)

2 Kebijakan PT. EFK mengenai minuman keras dan Obat Terlarang (diterangkan)
Alcohol & Drugs Policy (explained)

3 Kebijakan Kewenangan Penghentian Pekerjaan ( diterangkan )

Stop Work Authority (SWA) Policy (explained)

4 Kebijakan Transportasi ( diterangkan )

Trasnportation Policy (explained)

5 Kebijakan Lingkungan ( diterangkan )

Environment Policy (explained)

6 Kebijakan Pengamanan ( diterangkan )

Security Policy ( Explained )

7 Kebijakan Alat Pelindung Diri ( diterangkan )

Protective Personal Equipment Policy

8 Kebijakan Anti Penyuapan ( diterangkan )

Anti Bribery Policy

B. PENCEGAHAN KEBAKARAN / FIRE PREVENTION

1 Lokasi APAR, selang air dan pompa (diterangkan & ditunjukkan)
Location of fire extinguisher, water hoses dan pump (explained & shown)

2 Tempat Berkumpul Darurat dan Alarm (diterangkan & ditunjukkan)

Muster Point and Alarm (explained & shown)

3 Prosedur Darurat Evakuasi Kebakaran (diterangkan)

Fire Evacuation Emergency Procedure (explained)

C. MEDIS / MEDICAL
1 Petugas P3K (diterangkan & ditunjukkan)
First aid (explained & shown)

D. BAHAYA DI LOKASI / HAZARD ON SITE

1 Bahaya alami : sengatan matahari, binatang buas & berbisa (diterangkan)
Natural hazards: overheat, poisonous animal & beast.(explained)

2 Bahaya non-alami : kendaraan, handak, masalah keamanan dan kehumasan (diterangkan)

Non natural hazard : vehicles, explosive, security & public relation aspect (explained)

E. ALAT PELINDUNG DIRI / PERSONAL PROTECTIVE EQUIPMENT

1 APD standar : helm, sepatu safety, sarung tangan, baju kerja (diterangkan)
Standard PPEs : hardhat, rubber boot, glove, work clothes (diterangkan)

2 APD khusus : kaca mata, penutup telinga, dll (diterangkan)

Advanced PPEs : safety gogles, ear-muff, etc (explained)

3 Kebersihan Lingkungan (diterangkan)

Environment Clean (explained)

Tanda Tangan Personil ybs Tanda Tangan Petugas Induksi

Signature Signature of person who giving induction

Tanggal Tanggal
Date Date