CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES

1. Nama Perusahaan / Company Name :

2. Bidang Pekerjaan / Work Field :

3. Peralatan yang Digunakan / Equipments Used :

□ Perkakas Tangan / Hand Tools □ Mesin Las / Welding Machine

□ Alat Berat / Heavy Equipments (Dozer, Excavator, □ Tangga / Stairs
Compactor, Grader)

□ Trailer, Lowboy □ Rigging/Hoisting

□ Truk / Truck □ Kompresor / Compressor
□ Crane □ Scaffolding
4. Material yang Digunakan / Materials Used :

□ Bahan Kimia Berbahaya / Hazardous Chemicals □ ...

□ Bahan Peledak / Explosive Materials □ ...
□ Bahan Radioaktif / Radioactive Materials □ ...
5. Lingkup Pekerjaan / Scope of Work :
Catatan: jika lebih dari satu jenis pekerjaan, maka pastikan Anda melampirkan dokumen CSMS yang diminta seperti prosedur, pelat
dengan masing-masing jenis pekerjaan.

Note: if more than one kind of work, you shall to attached CSMS documents as requested such as procedure, training, and certifica
work

□ Fabricator □ Batching Plant

□ Forwarder □ Coating & Painting
□ Offshore □ Concrete & Foundation Activity
□ Diving □ Drainage
□ Pipe Laying □ Scaffolding
□ Trenching of Dredging □ Barge & Vessel Owner
□ Architectural Work □ Deepwell Activity
□ Instrument □ Piling
 CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES

□ Insulation □ Plumbing
□ Land Clearing □ Portacamp Mob. & Lifting
□ Logging □ Raw Water Intake Work
□ Mechanical □ Roofing & Siding
□ Medical Services Provider □ Security Service
□ NDT - Radiography □ Soil Investigation
Catatan / Note: NO.1 s/d 5 harus diisi oleh Perusahaan yang mengajukan penilaian CSMS / No.1 to 5 shall be completted b

Nama / Name
Tgl / Date
 CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES

NO KUESIONER / QUESTIONNAIRE EVIDENCE / LAMPIRAN BUKTI

I KEPEMIMPINAN & KEBIJAKAN K3LL / LEADERSHIP & HSE POLICY
Apakah perusahaan Anda memiliki kebijakan K3LL,
terdokumentasi & ditandatangani oleh pimpinan Salinan kebijakan K3LL perusahaan
1 perusahaan?
Does your company have HSE Policy, documented & approved
Copy of HSE policy
by Company Leader?

Bukti sosialisasi: daftar hadir dan materi

orientasi pekerja / tamu
Bagaimana cara perusahaan Anda mensosialisasikan
kebijakan K3LL?
(sebagai tambahan dapat melampirkan
poster kebijakan, banner)
2

Socialization evidences: attendance list and

orientation materials
How does your company socialize the HSE policy?
(in addition please attach poster, banner)

Siapakah orang yang bertanggung jawab dalam Riwayat kerja orang yang bertanggung
penerapan sistem manajemen K3LL di perusahaan jawab dalam penerapan sistem manajemen
Anda? K3LL di perusahaan
3

Who is the responsible person for implementing the HSE CV of the responsible person for implementing
management system at your company? the HSE management system at the company

Jelaskan bagaimana keterlibatan pemimpin perusahaan

Notulensi rapat P2K3 mengenai peninjauan
Anda terkait dengan penerapan sistem manajemen
ulang sistem manajemen K3LL
4 K3LL?
Please, explain the involvement of your company leader P2K3 minutes of meeting about review of HSE
regarding HSE management system implementation? management system
NILAI TOTAL / TOTAL SCORE
II KEPATUHAN TERHADAP PERATURAN PERUNDANGAN K3LL / HSE REGULATION COMPLIANCE
Apakah perusahaan Anda memiliki organisasi P2K3 dan Struktur organisasi dilengkapi dengan
LL? nama
1
Does your company have HSE committee organization? Complete organization chart with name

Sebutkan tugas dan tanggung jawab masing-masing Tugas dan tanggung jawab masing-masing
personil dalam penerapan sistem manajemen K3LL di personil dalam penerapan sistem
perusahaan Anda? manajemen K3LL
2
 CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES

2
Please, explain the job description of each personnel regarding Job description of each personnel in HSE
HSE management system implementation at your company? management system implementation

Apakah perusahaan Anda memiliki HSE personil yang

Riwayat pekerjaan serta sertifikasi
kompeten untuk memberikan panduan dalam program
(Depnaker / Migas) pimpinan HSE personil
3 K3LL?
Does your company have competent HSE personnel that drive CV and certification (Depnaker / Migas
the HSE program? certification) of HSE leader

Apakah perusahaan Anda melakukan pemeriksaan

Catatan hasil MCU dan rekapitulasi
kesehatan secara berkala?
4
Does your company carry out the Medical Check Up regularly? MCU record and recapitulation

Apakah perusahaan Anda memiliki program Jamsostek / Salinan kartu Jamsostek / asuransi
asuransi kesehatan dan kecelakaan? kesehatan dan kecelakaan
5
Does your company have Jamsostek / health and accident Copy of Jamsostek / health and accident
insurance program? insurance card
 CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES

Riwayat pekerjaan dan sertifikasi keahlian

Apakah perusahaan Anda memiliki personel kunci yang
kerja (contoh: sertifikasi welder, SIO
kompeten sesuai lingkup pekerjaan?
peralatan berat, dll)
6
Does your company have competent key personnel related to CV and certification of job skills (e.g. welder
the scope of work? certification, heavy vehicle license, etc.)

Apakah perusahaan Anda mengelola peralatan operasi

Sertifikat alat berat, kalibrasi peralatan,
dengan mematuhi ketentuan dari pihak berwenang
atau lainnya
(sertifikasi, kalibrasi)?
7
Does your company manage operation equipments comply Heavy vehicle certification, equipment
with regulations (calibration, certification)? calibration or etc.

NILAI TOTAL / TOTAL SCORE

III PELATIHAN / TRAINING

Salinan prosedur pelatihan K3LL,matrix

pelatihan, daftar hadir, materi pelatihan
Apakah perusahaan Anda memiliki program dan
internal (contoh: pelatihan APD, Bekerja di
memberikan pelatihan K3LL secara internal / eksternal?
ketinggian, pelatihan pengelolaan bahan
1 kimia, HSE induksi, dll)

Attendance list, copy of HSE training

Does your company have program and give HSE internal /
procedure, and training materials (e.g. PPE
external training?
training, chemical handling, induction, etc.)

Apakah perusahaan Anda memberikan pelatihan kepada Matriks dan sertifikat pelatihan bidang
karyawan sesuai dengan lingkup pekerjaan? keahlian kerja
2
Does your company give training to employee related to the
Matrix and training certificate of work skill
scope of work?
NILAI TOTAL / TOTAL SCORE
IV MANAJEMEN SUBKONTRAKTOR / MANAGEMENT OF SUBCONTRACTOR

Bagaimana perusahaan Anda mengelola subkontraktor Salinan prosedur pengelolaan

yang dapat mendukung program K3LL perusahaan? subkontraktor / CSMS
1
How does your company manage subcontractor for support Copy of subcontractor management procedure /
company HSE program? CSMS

Bagaimana perusahaan Anda memastikan bahwa

Hasil evaluasi subkontraktor / dokumen
subkontraktor memahami dan melaksanakan program
kontrak yang memuat aspek K3LL
K3LL?
2
How does your company ensure that subcontractor understand Subcontractor evaluation result / contract
and implement HSE program? document that mention the HSE aspect

NILAI TOTAL / TOTAL SCORE

 CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES

V HSE DALAM DESAIN, KONSTRUKSI, DAN KOMISIONING / HSE IN DESIGN, CONSTRUCTION, AND COMISS

Apakah perusahaan Anda memiliki prosedur kerja sesuai Daftar dan salinan prosedur kerja sesuai
dengan lingkup pekerjaan? dengan lingkup pekerjaan
1
Does your company have working procedure related to the List and copy of working procedure related to
scope of work? the scope of work

Apakah perusahaan Anda memiliki rencana program

Salinan rencana program K3LL
2 K3LL untuk pelaksanaan proyek?
Does your company have HSE plan for project execution? Copy of HSE plan

Apakah perusahaan Anda memiliki prosedur identifikasi Salinan prosedur identifikasi bahaya dan
bahaya dan penilaian risiko? penilaian risiko (JSA, RA)
3
Does your company have hazard identification and risk Copy of hazard identification and risk
assesment procedure? assesment procedure (JSA, RA)

Apakah perusahaan Anda memiliki contoh JSA dan RA Contoh JSA dan RA sesuai dengan detail /
sesuai dengan detail / lingkup pekerjaan? lingkup pekerjaan
4
Does your company have an example of JSA and RA related to Example of JSA and RA related to the detail /
the detail / scope of work? scope of work
 CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES

Apakah perusahaan Anda memiliki prosedur Izin Kerja

Salinan prosedur Izin Kerja Aman
5 Aman?
Does your company have Permit to Work procedure? Copy of Permit to Work procedure

Salinan prosedur APD (perawatan,

Apakah perusahaan Anda memiliki prosedur tentang APD penyimpanan, dll) dan daftar APD sesuai
dan membuat daftar APD sesuai spesifikasi lingkup dengan lingkup pekerjaan (jenis dan
pekerjaan? spesifikasi sesuai standar nasional /
internasional)
6
Copy of PPE procedure (maintenance, storage,
Does your company have PPE procedure and make a list of etc.) and list of PPE related to the scope of
PPE and specification related to the scope of work? work (type and specification according to
national / international standards)

Bagaimana perusahaan Anda memastikan APD telah

diterima oleh karyawan sesuai dengan lingkup Catatan distribusi dan inventarisasi APD
7 pekerjaan?
How does your company ensuring PPE accept properly by
PPE distribution record and inventory
worker related to the scope of work?

Apakah perusahaan Anda memiliki program Higiene

Laporan pengukuran Higiene Industri
Industri? (pencahayaan, debu, suhu, ergonomi, dll)
8
Does your company have Industrial Hygiene program?
Industrial Hygiene measurement report
(illumination, dust, temperature, ergonomic, etc.)

Apakah perusahaan Anda memiliki prosedur Salinan prosedur pengendalian tumpahan

pengendalian tumpahan bahan kimia? bahan kimia

9
Does your company have chemical spill handling procedure? Copy of chemical spill handling procedure

Apakah perusahaan Anda memiliki prosedur pengelolaan

Salinan prosedur pengelolaan limbah
limbah?
10
Does your company have waste management procedure? Copy of waste management procedure

Bagaimana cara perusahaan Anda menangani limbah

B3? (oli bekas, tumpahan minyak, material B3 Manifest limbah B3
kadaluarsa, pelarut, dll)
11
How does your company handle hazardous waste? (used oil,
Manifest of hazardous waste
oil spill, expired hazardous material, solvent, etc.)
 CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES

NILAI TOTAL / TOTAL SCORE

VI MANAJEMEN PERUBAHAN / MANAGEMENT OF CHANGE
Apakah perusahaan Anda memiliki prosedur manajemen
Salinan prosedur manajemen perubahan
perubahan?
1
Does your company have management of change procedure? Copy of management of change procedure

Salinan form manajemen perubahan

Bagaimana cara perusahaan Anda melakukan (contoh: perubahan struktur organisasi
manajemen perubahan? perusahaan, perubahan penggunaan
2 peralatan di tempat kerja, dll)

Copy of management of change form (e.g.

How does your company perform management of change? organizational-structural change, equipment
change, etc.)
NILAI TOTAL / TOTAL SCORE
VII INSPEKSI / INSPECTION
Apakah perusahaan Anda melakukan inspeksi umum Bukti inspeksi K3LL (min: 2 periode
tempat kerja? inspeksi)

1
Does your company carry out the general workplace Evidence of HSE inspection (min: 2 inspection
inspection? periods)
 CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES

Bagaimana cara perusahaan Anda untuk menindak lanjuti

Laporan tindak lanjut hasil temuan
temuan inspeksi?

2
How does your company follow up the inspection findings? Report of follow up inspection finding

Apakah peralatan kerja Anda diinspeksi sebelum dikirim

Bukti hasil inspeksi peralatan
ke lokasi proyek (mobilisasi)?
3
Does your company equipments inspected before sent to
Evidence of equipment inspection results
project site area (mobilization)?

Apakah perusahaan Anda melakukan inspeksi pada alat

Jadwal dan hasil inspeksi alat kerja
kerja yang digunakan?

4
Does your company do inspection for working equipments? Equipment inspection schedule and result

NILAI TOTAL / TOTAL SCORE

VIII KOMUNIKASI / COMMUNICATION
Apakah perusahaan Anda melakukan rapat toolbox / Daftar hadir dan materi rapat toolbox /
safety talk? safety talk
1
Does your company carry out toolbox / safety talk meeting Attendance list and materials of toolbox / safety
program? talk meeting

Apakah perusahaan Anda mengkomunikasikan Job

Daftar hadir komunikasi JSA / RA
Safety Analysis / Risk Assessment?
2
Does your company communicate Job Safety Analysis / Risk
Attendance list JSA / RA communication
Assessment?

Apakah perusahaan Anda memiliki sarana komunikasi Contoh HSE news, HSE bulletin, HSE Alert
K3LL lainnya? (HSE news, HSE bulletin, HSE Alert dll) dll
3
Does your company have other HSE communication tool? Example of HSE news, HSE bulletin, HSE Alert
(HSE news, HSE bulletin, HSE Alert etc.) etc.

NILAI TOTAL / TOTAL SCORE

IX TANGGAP DARURAT / EMERGENCY RESPONSE
Apakah perusahaan Anda memiliki prosedur emergensi? Salinan prosedur emergensi
1
Does your company have emergency procedure? Copy of emergency procedure
 CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES

Apakah perusahaan Anda melakukan pelatihan

Laporan pelatihan emergensi
2 emergensi secara berkala?
Does your company do the emergency drill regularly? Emergency drill report
NILAI TOTAL / TOTAL SCORE
PELAPORAN DAN PENYELIDIKAN KEJADIAN KECELAKAAN DAN PENCEMARAN LINGKUNGAN /
X
REPORTING AND INVESTIGATION OF INCIDENT AND ENVIRONMENTAL POLLUTION
Apakah perusahaan Anda memiliki prosedur pelaporan Salinan prosedur pelaporan kecelakaan
kecelakaan kerja? kerja
1
Does your company have incident reporting procedure? Copy of incident reporting procedure

Statistik kecelakaan tiga tahun terakhir

Apakah perusahaan Anda mencatat statistik kecelakaan
(jika ada, mohon lampirkan contoh laporan
dalam 3 tahun terakhir? (LTIFR, LTISR, dll)
investigasi kecelakaan)
2
Accident statistic report for last 3 years
Does your company record the accident statistic for last 3
(if available, please attach example of accident
years? (LTIFR, LTISR, etc.)
investigation report)

NILAI TOTAL / TOTAL SCORE

XI DOKUMENTASI / DOCUMENTATION

Kumpulan daftar dokumen, salinan

Bagaimana cara perusahaan Anda mendokumentasikan
prosedur pendokumentasian, dan lembar
dan memperbaharui program K3LL?
revisi
1
How does your company document and renew the HSE Master list of HSE document, copy of document
program? control prosedur, and historical sheet

NILAI TOTAL / TOTAL SCORE

 CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES

XII EVALUASI / EVALUATION

Apakah perusahaan Anda memiliki prosedur evaluasi
1 K3LL?
Does your company have HSE evaluation procedure?
Apakah perusahaan Anda melakukan internal audit
K3LL?
Salinan prosedur evaluasi K3LL
Copy of HSE evaluation procedure
Jadwal dan laporan hasil internal audit
K3LL

2
Does your company carry out HSE internal audit? Schedule and report of HSE internal audit

Salinan sertifikat OHSAS 18001: 2007, ISO

Apakah perusahaan Anda memiliki sertifikat sistem
14001: 2004, SMK3, penghargaan jam
manajemen K3LL dari pemerintah / badan sertifikasi?
kerja aman, dll
3
Copy certificate of OHSAS 18001:2007, ISO
Does your company have HSE management system
14001: 2004, SMK3, reward for zero accident,
certification from government / certification agencies?
etc.)
NILAI TOTAL / TOTAL SCORE
XIII REWARD DAN PUNISHMENT / REWARD AND PUNISHMENT
Apakah perusahaan Anda memiliki prosedur tentang
Salinan prosedur promosi / reward HSE
promosi / reward HSE?
1
How does your company have HSE promotion / reward
Copy of HSE promotion / reward procedure
procedure?
Salinan penghargaan atau pemberian
Bagaimana perusahaan Anda menerapkan program hadiah kepada pekerja
reward dan punishment HSE? Salinan sangsi disiplin kepada pekerja
2 mengenai pelanggaran K3LL
Copy of reward for worker
How does your company implement HSE reward and
Copy of punishment for worker regarding HSE
punishment program?
violation
NILAI TOTAL / TOTAL SCORE
NILAI TOTAL KESELURUHAN / TOTAL SCORE OVERALL
Minimal Skor kelulusan Offshore 70
Minimal Skor kelulusan High Risk 60
Minimal Skor kelulusan Low Risk 50

PT………. HAS PASSED THE QUALIFICATI

Prepared by,
date…………
 CONTRACTOR SAFETY MANAGEMENT SYSTEM QUES

HSE Engineer
YSTEM QUESTIONNAIRE

□ Mesin Pilling / Pilling Machine

□ Pompa / Pumps
□ Kapal Laut / Vessel
□…
□…

ti prosedur, pelatihan, dan sertifikasi sesuai

ning, and certification related to each kind of

□ Earth Work & Earth Moving

□ Chemical Cleaning
□ Electrical
□ Cathodic Protection Activity
□ Post Trenching
□ Weather Forecast Activity
□ HVAC Installation
□ Steel Structure
YSTEM QUESTIONNAIRE

□ Temporary Facility
□ Topography
□ Transportation Provider
□…
□…
□…
shall be completted by Company who propose CSMS assessment

Perwakilan Perusahaan,
Company Representative,

:
:
YSTEM QUESTIONNAIRE

NILAI / SCORE BOBOT / WEIGHT KETERANGAN / REMARK

0 2

0 2

0 2

0 2

0 8
ANCE

0 2

0 2
YSTEM QUESTIONNAIRE

0 2

0 3

0 2

0 2
YSTEM QUESTIONNAIRE

0 2

0 2

0 15

0 4

0 2

0 6

0 2

0 2

0 4
YSTEM QUESTIONNAIRE

N, AND COMISSIONING

0 2

0 4

0 2

2
YSTEM QUESTIONNAIRE

0 2

0 2

0 2

0 2

0 2

0 2

0 2
YSTEM QUESTIONNAIRE

0 24

0 2

0 2

0 4

0 2
YSTEM QUESTIONNAIRE

0 2

0 2

0 2

0 8

0 2

0 2

0 2

0 6

0 3
YSTEM QUESTIONNAIRE

0 3

0 6
NGAN /

0 2

0 2

0 4

0 2

0 2
YSTEM QUESTIONNAIRE

0 3

0 3

0 3

0 9

0 2

0 2

0 4

0 100

UALIFICATION

Reviewed by,
YSTEM QUESTIONNAIRE

HSE Senior Engineer