SURAT PERINGATAN

FM/SFT-1/08 Rev. 1 Hal.: 1 Dari : 1

No. :.............................................................................
Kepada Yth. :.............................................................................
Proyek :.............................................................................

Pada hari ini . . . . . . . . . . . . . . . . . . Tgl . . . . . . . . . . . . . . . . . . . . . . . . . Jam . . . .. . . . . . . . . . . .

Kami telah menemukan hal (sesuai tanda ) berikut

 Hampir terjadi korban kecelakaan  Keadaan / tindakan yang tidak aman

 Penyimpangan ketentuan K3  Penyimpangan ketertiban proyek

Yang menjadi tanggung jawab perusahaan / pihak anda, dengan ringkasan peristiwa (lokasi, korban orang, kerusakan material,
situasi, dsb) sebagaimana penjelasan dibawah ini

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 Sesuai laporan ketidaksesuaian LK-K3 terlampir

Instruksi / catatan / peringatan dari Tim K3

 Kegiatan pekerjaan sebagaimana yang dimaksud di atas ‘dihentikan’ sementara, sampai direkomendasikan oleh Safety
Supervisor untuk dilanjutkan.
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Safety Supervisor

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TINDAKAN PERBAIKAN
Batas waktu perbaikan yang dijanjikan
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(Bagian ini diisi oleh penerima Surat Peringatan, copy untuk file penerima dan lembaran asli dikembalikan ke Safety Supervisor)