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Terbit : 08 Januari 2019


FORM LAPORAN HASIL
No Rev :0
INSPEKSI DAN AUDIT Tgl Rev :-
Hal : 1/2

FORM LAPORAN HASIL INSPEKSI & AUDIT

No. PPE/APD Diperiksa/Checked Substandard Saran/Comment


1. Topi Keselamatan / Hard Hat
2. Kacamata Pengaman /
Safety Glasses
3. Sepatu Keselamatan / Safety
Shoe
4. Pelindung Pendengaran
/Hearing Protection
5. Sarung Tangan / Gloves
6. Pelindung Pernafasan
/Respirator
7. Lain-lain/Other
No Equipment & Safety Diperiksa / Checked Substandard Saran/Comment
Signs/Perlengkapan & Tanda
Pengaman
1. Alat Pemadam Api (Fire
Extinguisher)
2. Lampu (Lighting)
3. Tanda-tanda Evakuasi
(Evacuation Signs)
4. Tanda-tanda Larangan
(Danger Signs)
5. Kabel Listrik (Electrical
Cables)
6. Perlengkapan Pertolongan
Pertama (First Aid Kit)
7. Penguncian-Pelabelan (Tag-
Label)
No Kebersihan / Housekeeping Diperiksa / Checked Substandard Saran/Comment
1 Tangga (Ladders)
2. Penampungan Sampah
(Trash Storage)
3 Lantai (Floor)
Keterangan/remarks :

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