CSTS FFT Review Form-Version 1.

00
Dec 22nd 2016

FIT FOR TASK (FFT) REVIEW FORM

FORM INI DIISI OLEH KARYAWAN/FILLED BY THE REQUESTOR (anda bisa memilih lebih dari
satu/ you may tick √ more than one)

TANGGAL MCU/MCU DATE

[ Pre-employment [ Visitor [ Periodic-Annual

Project Non CSTS/Contractor Others
[ [ [
CSTS Post Absence
[ [
IDENTITAS DIRI/PERSONAL IDENTITY

Nama/Name Jenis Kelamin/Gender

Kewarganegaraan/Nationality Tempat Tanggal

Lahir/Place & Date of
Birth
Usia/Age Alamat/Address

Email No. Telp/Phone

Number
Perusahaan/Company Pekerjaan/Job Title

Departemen/Department Employee
ID/Sequential number
FFT Sertifikat dikirim ke/Medical Cerificate sent to:
 CSTS FFT Review Form-Version 1.00
Dec 22nd 2016

RIWAYAT PAPARAN DI TEMPAT KERJA/WORK HAZARD EXPOSURE

Apakah anda saat ini terpapar dengan paparan dibawah ini? Have you exposed with work hazard below?

Mohon jawaban diisi (√) untuk jawaban ya di samping jenis paparan. Jawaban bisa lebih dari satu/Please
fill with (√) for Yes answer in blank column beside the hazard exposure. You may thick more than one.

Jenis Paparan/Hazard (√) Jenis Paparan/ (√)

exposure Hazard exposure
Pelarut/Solvent Bekerja di
ketinggian/Working at
high
Formaldehid/Formaldehyde Gerakan repetitive/
Repetitive movement
Merkuri/ Mercury Gerakan mengangkat/
Manual handling
Asap/ Smoke Operator alat berat/
Heavy equipment
operator
Debu/ Dust Supir/ Profesional
driver
Silika/ Silica Bekerja di ruang
tertutup/ Confined
space entry
Asbes/ Asbes Bekerja dengan
komputer/ DSE
Fume Tenaga medis/Medical
professional
Bahan kimia lainnya/Other Bekerja dengan
chemical limbah/ Sewage
worker
Suhu sangat panas/ Hot Penjamah makanan/
temperature Food handler
Suhu sangat dingin/ Cold Stress kerja/ Stress
temperature work
Radiasi pengion/ Ionizing Shift kerja/ Shift work
radiation
Bising/ Noise Jam kerja panjang /
Long work hours
Getaran/Vibration Rotasi kerja/ Rotation
work
Bekerja di tempat
terpencil /Remote site worker