No : …………………………………..

Formulir SURAT IJIN BEKERJA / PERMIT TO WORK Form

* Hanya pekerjaan tertera dibawah ini yang dicakup oleh Surat * Only the work that is detailed below is covered by this
Izin Bekerja ini. Perhatikan persyaratan surat izin dengan permit. Review the permit requirements completely prior to
menyeluruh sebelum memulai pekerjaan commencing work
** Tidak boleh ada karyawan yang memasuki ruang tertutup (atau atmosfer
yang berbahaya) tanpa menggunakan tali penyelamat dan tanpa ** No employee may enter a confined space (or hazardous atmosphere)
without being attached to a lifeline and without another employee
kehadiran karyawan lain, pada tempat masuk, sepanjang in attendance, at the entrance, at all times.
waktu.
*** Hanya Kepala Seksi yang boleh mengeluarkan izin ini. *** Only Section Heads may issue these permits.
**** Permit ini hanya berlaku untuk satu (1) shift kerja. **** This permit is only valid for one (1) working shift.

Informasi Dasar (Harus Diisi Oleh Pemohon PtW)

Basic Information (To Be Completed By Person Requesting PtW)
Company Name Cabang
(PTTU / Contractor) Branch
Departemen Seksi / Bagian
Department Section
Supervisor Name Supervisor Name
(Contractor) (PTTU)
Tempat & Waktu / Time & Place

Tanggal Penerbitan Jam Penerbitan

Date of Issue Time Of Issue
Lamanya Pekerjaan Mulai Selesai
Expected Duration From To
Lokasi yang tepat (Nomor Alat / Gedung)
Exact Location (Fleet/Building Number)
Deskripsi Tugas Yang Ingin/Harus Dikerjakan
Description Of Work That Must/Will Be Done
Nama Orang Yang Diberikan Izin Ini
Name Of Person That This Permit Is Issued To
Peralatan khusus yang diperlukan
Special Tools that are required
Bahaya Utama yang berhubungan dengan tugas
Main Hazards associated with the task

Pekerjaan Umum / General Work

1 Apakah daerah telah diperiksa & diamankan ? Has the area been checked & made safe? N/A Yes No
2 Apakah udara telah dibersihkan? Has the area been purged? N/A Yes No
3 Apakah daerah bertegangan listrik? Is there High voltage in the area? N/A Yes No
4 Apakah bejana telah dibuang tekanannya? Has the vessel been depressurised? N/A Yes No
5 Apakah perlu uji gas sebelum pekerjaan mulai? Are gas tests required before the job starts? N/A Yes No
6 Apakah anda telah menguji gas di daerah itu? Have you tested for gas in the area? N/A Yes No
7 Apakah uji gas diperlukan pada saat bekerja? Are gas tests required during the job? N/A Yes No
8 Sudahkah anda menguji gas selama bekerja? Did you test for gas during the job? N/A Yes No
9 Ada bahan mudah terbakar? Are there any flammable substances? N/A Yes No
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Formulir SURAT IJIN BEKERJA / PERMIT TO WORK Form

Pekerjaan Umum (lanjutan) / General Work (continued)

10 Apakah bahan mengandung bahan kimia ? Are there chemical subtances? N/A Yes No
11 Apakah bahan mengandung Oli / Bahan bakar? Are there oils / fuels present? N/A Yes No
12 Apakah perlu pelindung kebakaran tambahan? Are additional fire precations required? N/A Yes No
13 Apakah perlu Prosedur Tugas Spesifik (JSA / PTS)? Is a Task Specific Procedure (JSA / TSP) required? (WIN) N/A Yes No
14 Apakah JSA/PTS dilampirkan? Is the JSA/TSP (WIN) attached ? N/A Yes No
15 Apakah WIN telah didiskusikan dengan karyawan? Has the WIN been discussed with the employees? N/A Yes No
16 Apakah peralatan pernafasan diperlukan? Is respitory equipment required? N/A Yes No
17 Apakah perlu tali penyelamat/sabuk keselamatan? Is a lifeline / safety harness required? N/A Yes No
18 Apakah benda / mesin telah di-LOTO? Has the item / machine been locked-out (LOTO)? N/A Yes No

Pekerjaan Panas (di daerah berbahaya) / Hot Work (in hazardous areas)

1 Springkler, selang air atau APAR berfungsi dgn baik? Springkler, fire hose or extinguisher in good working order? N/A Yes No
2 Peralatan pemotongan / pengelasan diperiksa? Cutting / welding equipment inspected? N/A Yes No
3 Semua orang telah terlibat untuk peralatan api? All person involved trained on fire equipment? N/A Yes No
4 Supervisor daerah tersebut mengetahui? Area supervisor notified? N/A Yes No
5 Lantai / daerah bebas dari bahan mudah terbakar? Floors / Area clear of flammables? N/A Yes No

Pekerjaan di Ruang Tertutup / Work in Confined Spaces

1 Uji gas diperlukan sebelum atau sesudah tugas? Are gas test required before or during the job? N/A Yes No
2 Anda sudah menguji gas sebelum & sesudah tugas? Did you test for gas before and during the job? N/A Yes No
3 Udara kerja sudah dibersihkan? Work area purged? N/A Yes No
4 Apakah peralatan pernafasan diperlukan? Is respitory equipment required? N/A Yes No
5 Apakah karyawan telah menerima pelatihan? Have the employees received coaching? N/A Yes No

Tindakan Pengamanan / Mitigating Actions Taken

1 Menggunakan alat pelindung diri, berupa:- / Use Personal Protective Equipment, as follows:-
a N/A Yes No
b N/A Yes No
c N/A Yes No
d N/A Yes No
e N/A Yes No
f N/A Yes No
g N/A Yes No
h N/A Yes No
2 Perlu Penjelasan di tempat? / Is at-the-scene Explanation Required? N/A Yes No

Bagian dari / Part of - SHE.SOP.013.R00 Form Number : SHE.FRM.030.R00

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Formulir SURAT IJIN BEKERJA / PERMIT TO WORK Form

Persetujuan / Approval
Departemen SHE
Saya telah memeriksa peralatan / daerah / benda yang terinci diatas dan saya menilai aman untuk
melaksanakan pekerjaan yang telah disebutkan.
Yes No
I have inspected the equipment / area / item detailed above and I consider it safe for the work as described to
be conducted.
Nama Staf K3L Tanda Tangan Tanggal
SHE Officer Name Signature Date
Penanggung Jawab Sub Kontraktor / Sub Contractor Responsible
Anak buah saya dan saya telah menerima pelatihan Induksi K3L dan kami mengetahui Perlindungan Safety
yang diperlukan.
Yes No
My staff and I have received the Safety Induction training and we are aware of the required Safety
Precautions.
Saya pribadi sudah memeriksa izin ini dan juga peralatan / daerah / benda yang terrinci diatas.
Yes No
I have personally checked this permit and also the equipment / area / items detailed above.
Saya mengerti sifat dan lingkup dari pekerjaan serta perlindungan yang harus diikuti selama penyelesaian
tugas.dengan aman.
Yes No
I understand the nature and extent of the work as well as the precautions to be followed whilst completing the
work.
Saya bisa melakukan tugas yang dimaksud dengan selamat.
Yes No
I can safely carry out the work outlined.
Nama Tanda Tangan Tanggal
Name Signature Date
Departemen Lain yang Terlibat / Other Departments Involved
Saya mengetahui bahwa tugas yang dimaksud diatas berada dalam daerah tanggung jawab saya.
Yes No
I am aware of the above proposed work will be done in my area of responsibility.
Saya pribadi telah memeriksa surat izin ini dan juga rincian peralatan / daerah / benda tersebut diatas.
Yes No
I have personally checked this permit and also the equipment / area / items detailed above.
Saya mengerti sifat dan lingkup dari tugas.
Yes No
I understand the nature and extent of the work.
Saya yakin bahwa tugas ini bisa dilakukan dengan aman.
Yes No
I am convinced that the work can be completed safely.
Nama Tanda Tangan Tanggal
Name Signature Date
Inspeksi Penyelesaian / Completion Inspection
Saya telah memeriksa daerah tempat tugas dilakukan. Saya dengan I have inspected the area where the work was done. I hereby
ini menyatakan bahwa tugas telah dilakukan dengan Aman dan declare that it was done Safely and that the area has been left in
daerah ini ditinggalkan dalam keadaan bersih dan rapi. a clean and tidy condition.
Nama Tanda Tangan Tanggal
Name Signature Date
Saya telah memeriksa ulang daerah dimana dilakukan tugas. Saya I have over-inspected the area where the work was done. I
dengan ini menyatakan tugas telah dilakukan dengan aman & hereby declare that it was done Safely and that the area has
daerah bersih, rapi. been left in a clean and tidy condition.
Nama Tanda Tangan Tanggal
Name Signature Date

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T IJIN BEKERJA / PERMIT TO WORK Form
Persetujuan / Approval
Departemen SHE

No

wab Sub Kontraktor / Sub Contractor Responsible

No

No

No

No

Lain yang Terlibat / Other Departments Involved

No

No

No

No

ksi Penyelesaian / Completion Inspection

I have inspected the area where the work was done. I hereby
declare that it was done Safely and that the area has been left in
a clean and tidy condition.

I have over-inspected the area where the work was done. I

hereby declare that it was done Safely and that the area has
been left in a clean and tidy condition.

SHE.FRM.030.R00