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OBSERVASI TUGAS TERENCANA
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A.

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B. FORMULIR INSPEKSI UMUM TERENCANA

KANTOR DAN GUDANG
Nama site : …………………… Lokasi / Area : ………………………
Departemen: …………………… Tanggal : ………………………

NILAI KODE TINGKAT

PANDUAN DALAM MELAKUKAN TINDAKAN PENGENDALIAN BAHAYA
RESIKO BAHAYA BAHAYA
101 – 125 AA Bahaya Kritis Berhenti, isolasi, SEGERA laporkan ke atasan, dan perbaiki segera.
45 – 100 A Resiko Tinggi Berhenti, SEGERA laporkan ke atasan, putuskan : lanjutkan dengan catatan atau perbaiki segera.
9 – 44 B Resiko Sedang Laporkan ke atasan dan perbaiki setelah bahaya AA – A selesai.
2–8 C Resiko Rendah Laporkan ke atasan dan perbaiki setelah bahaya AA – A – B selesai.

N POIN POIN
HAL YANG DIPERIKSA
O MAKS. AKTUAL
1 Atap, dinding, pintu, jendela dalam kondisi bersih, baik dan tidak rusak. 4
2 Toilet / kamar mandi umum terpelihara, dan dibersihkan secara rutin. 4
3 Permukaan lantai dan gang untuk berjalan bersih dan tidak licin. 4
4 Penerangan (buatan / alami) memadai, tidak kurang atau tidak silau. 4
5 Ventilasi (buatan / alami) memadai. 4
Penyimpanan rapi, diatas rak, dan untuk penumpukan dilantai di dalam garis
6 4
demarkasi.
7 Housekeeping dan kebersihan di area sekitar bangunan memadai. 4
8 Penumpukan di halaman (yard) rapi, di area demarkasi, dan ada gang. 4
9 Halaman parkir rata, bersih, luas dan semua kendaraan parkir mundur. 4
10 Tempat sampah cukup dan dikosongkan secara rutin. 4
11 Instalasi listrik, saklar, kabel dalam kondisi baik dan aman. 4
12 Semua tangga dalam kondisi baik, kode warna standar dan ada KIP. 4
Penyimpanan tabung las berdiri, terikat, dipisahkan antara tabung kosong dan isi,
13 4
dipisahkan antara tabung O2, N2, Acetilene.
14 Lokasi dekat dengan klinik. Jika jauh dilengkapi dengan peralatan P3K. 4
Penyimpanan bahan mudah terbakar sesuai standar dan terpisah dengan barang
15 4
lainnya.
16 Semua furniture (lemari, kursi, meja, dll) bersih dan ergonomis. 4
17 Penyimpanan bahan B3 tersendiri dan dilengkapi MSDS. 4
18 Rambu, tanda K3LH dan kode warna cukup dan sesuai standar. 4
19 Semua karyawan memakai APD sesuai standar. 4
20 Ada rambu “Dilarang Masuk Selain Petugas” di pintu ruang khusus. 4
21 Alat dan instalasi pemadam kebakaran memadai dan diinspeksi rutin. 4
22 Dilengkapi dengan alarm emergency dan tempat berkumpul darurat. 4
TOTAL NILAI 88

PERSENTASE = (Total poin aktual / Total poin maks.) x 100 %

Keterangan : 90 – 100% sesuai dg standar  poin 4, 50 – 74% sesuai dg standar  poin 2,

75 – 89% sesuai dg standar  poin 3, < 50% sesuai dg standar  poin 1.

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Inspeksi oleh, Inspeksi ulang oleh, Inspeksi ulang oleh,

(……………………) (……………………) (……………………)

Jabatan : Jabatan : Jabatan :
Tanggal : Tanggal : Tanggal :

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B.

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C. D. E. F.
G. H. I. J.
K. L. M. N.
O. P. Q. R.
S. T. U. V.
W. X. Y. Z.
AA. BB. CC. DD.
EE. FF. GG. HH.
II. JJ. KK. LL.
MM. NN. OO. PP.
QQ. RR. SS. TT.
UU. VV. WW. XX.
YY. ZZ. AAA. BBB.
CCC. DDD. EEE. FFF.
GGG. HHH. III. JJJ.
KKK. LLL. MMM. NNN.
OOO. PPP. QQQ. RRR.
SSS. TTT. UUU. VVV.
WWW. XXX. YYY. ZZZ.
AAAA. BBBB. CCCC. DDDD.
EEEE. FFFF. GGGG.HHHH.
IIII. JJJJ. KKKK. LLLL.
MMMM. NNNN. OOOO.PPPP.
QQQQ. RRRR. SSSS. TTTT.
UUUU. VVVV. WWWW. XXXX.
YYYY. ZZZZ. AAAAA. BBBBB.
CCCCC. DDDDD. EEEEE.FFFFF.
GGGGG. HHHHH. IIIII. JJJJJ.
KKKKK. LLLLL. MMMMM. NNNNN.

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OOOOO. PPPPP. QQQQQ.RRRRR.

SSSSS. TTTTT. UUUUU.VVVVV.
WWWWW. XXXXX.YYYYY.
ZZZZZ. AAAAAA.
BBBBBB. CCCCCC. DDDDDD.
EEEEEE. FFFFFF. GGGGGG.
HHHHHH. IIIIII. JJJJJJ.
KKKKKK. LLLLLL. MMMMMM.
NNNNNN. OOOOOO. PPPPPP.
QQQQQQ. RRRRRR. SSSSSS.
TTTTTT. UUUUUU. VVVVVV.

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WWWWWW.

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XXXXXX.YYYYYY.
ZZZZZZ. AAAAAAA.
BBBBBBB.
CCCCCCC.
DDDDDDD. EEEEEEE.
FFFFFFF.
GGGGGGG.
HHHHHHH. IIIIIII.
JJJJJJJ.
KKKKKKK.
LLLLLLL. MMMMMMM.
NNNNNNN.
OOOOOOO.
PPPPPPP. QQQQQQQ.
RRRRRRR. SSSSSSS. TTTTTTT.
UUUUUUU.
VVVVVVV. WWWWWWW. XXXXXXX.
YYYYYYY.
ZZZZZZZ. AAAAAAAA. BBBBBBBB.
CCCCCCCC.
DDDDDDDD. EEEEEEEE. FFFFFFFF.
GGGGGGGG.
HHHHHHHH. IIIIIIII. JJJJJJJJ.
KKKKKKKK.
LLLLLLLL. MMMMMMMM. NNNNNNNN.
OOOOOOOO.
PPPPPPPP. QQQQQQQQ. RRRRRRRR.
SSSSSSSS.
TTTTTTTT. UUUUUUUU. VVVVVVVV.
WWWWWWW
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AAAAAAAAA
BBBBBBBBB. CCCCCCCCC. DDDDDDDDD.
EEEEEEEEE.
FFFFFFFFF. GGGGGGGGG. HHHHHHHHH.
IIIIIIIII.
JJJJJJJJJ. KKKKKKKKK. LLLLLLLLL.
MMMMMMMM
NNNNNNNNN. OOOOOOOOO. PPPPPPPPP.
QQQQQQQQQ
RRRRRRRRR. SSSSSSSSS. TTTTTTTTT.
UUUUUUUUU
VVVVVVVVV. WWWWWWWWW. XXXXXXXXX.
YYYYYYYYY.
ZZZZZZZZZ. AAAAAAAAAA. BBBBBBBBBB.
CCCCCCCCC
DDDDDDDDDD. EEEEEEEEEE. FFFFFFFFFF.
GGGGGGGGG
HHHHHHHHHH. IIIIIIIIII. JJJJJJJJJJ.
KKKKKKKKK
LLLLLLLLLL. MMMMMMMMMM. NNNNNNNNNN.
OOOOOOOOO
PPPPPPPPPP. QQQQQQQQQQ. RRRRRRRRRR.
SSSSSSSSSS
TTTTTTTTTT. UUUUUUUUUU. VVVVVVVVVV.
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AAAAAAAAA
BBBBBBBBBBB.CCCCCCCCCCC. DDDDDDDDDDD.
EEEEEEEEEE
FFFFFFFFFFF. GGGGGGGGGGG. HHHHHHHHHHH.
IIIIIIIIIII.

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JJJJJJJJJJJ. KKKKKKKKKKK. LLLLLLLLLLL.

MMMMMMMM
NNNNNNNNNNN. OOOOOOOOOOO.
PPPPPPPPPP
QQQQQQQQQQQ. RRRRRRRRRRR.
SSSSSSSSSSS.
TTTTTTTTTTT. UUUUUUUUUUU.
VVVVVVVVVVV.
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YYYYYYYYYYY.
ZZZZZZZZZZZ. AAAAAAAAAAAA.
BBBBBBBBBBBB.
CCCCCCCCCCCC. DDDDDDDDDDDD.
EEEEEEEEEEEE. FFFFFFFFFFFF. GGGGGGGGGGGG.
HHHHHHHHHHHH. IIIIIIIIIIII. JJJJJJJJJJJJ.
KKKKKKKKKKKK. LLLLLLLLLLLL. MMMMMMMMMMMM.

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NNNNNNNNNNNN.

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OOOOOOOOOOOO.PPPPPPPPPPPP.
QQQQQQQQQQQQ.RRRRRRRRRRRR.
SSSSSSSSSSSS.TTTTTTTTTTTT.
UUUUUUUUUUUU. VVVVVVVVVVVV.
WWWWWWWWWWWW.XXXXXXXXXXXX.
YYYYYYYYYYYY. ZZZZZZZZZZZZ.
AAAAAAAAAAAAA.
BBBBBBBBBBBBB.
CCCCCCCCCCCCC.DDDDDDDDDDDDD.
EEEEEEEEEEEEE.
FFFFFFFFFFFFF.
GGGGGGGGGGGGG.HHHHHHHHHHHHH.
IIIIIIIIIIIII. JJJJJJJJJJJJJ. KKKKKKKKKKKKK.
LLLLLLLLLLL
MMMMMMMMMMMMM. NNNNNNNNNNNNN. OOOOOOOOOOOOO
PPPPPPPPPP
QQQQQQQQQQQQQ. RRRRRRRRRRRRR. SSSSSSSSSSSSS.
TTTTTTTTTTT
UUUUUUUUUUUUU. VVVVVVVVVVVVV. WWWWWWWWWWW XXXXXXXXXX
YYYYYYYYYYYYY. ZZZZZZZZZZZZZ. AAAAAAAAAAAAAA
BBBBBBBBB
CCCCCCCCCCCCCC. DDDDDDDDDDDDDD. EEEEEEEEEEEEEE.
FFFFFFFFFFF
GGGGGGGGGGGGGG. HHHHHHHHHHHHHH. IIIIIIIIIIIIII.
JJJJJJJJJJJJ
KKKKKKKKKKKKKK. LLLLLLLLLLLLLL. MMMMMMMMMMMMNNNNNNNNN
OOOOOOOOOOOOOO. PPPPPPPPPPPPPP. QQQQQQQQQQQQQ
RRRRRRRRR
SSSSSSSSSSSSSS. TTTTTTTTTTTTTT. UUUUUUUUUUUUUU
VVVVVVVVVV
WWWWWWWWWWWWWW. XXXXXXXXXXXXXX. YYYYYYYYYYYYYY.
ZZZZZZZZZZZ
AAAAAAAAAAAAAAA. BBBBBBBBBBBBBBB. CCCCCCCCCCCCCC
DDDDDDDDD
EEEEEEEEEEEEEEE. FFFFFFFFFFFFFFF. GGGGGGGGGGGGG
HHHHHHHHH
IIIIIIIIIIIIIII. JJJJJJJJJJJJJJJ. KKKKKKKKKKKKKK
LLLLLLLLLLL
MMMMMMMMMMMMMMM. NNNNNNNNNNNNNNN. OOOOOOOOOOOOO
PPPPPPPPPP
QQQQQQQQQQQQQQQ. RRRRRRRRRRRRRRR. SSSSSSSSSSSSSSS
TTTTTTTTTTT
UUUUUUUUUUUUUUU. VVVVVVVVVVVVVVV. WWWWWWWWWWW XXXXXXXXXX
YYYYYYYYYYYYYYY. ZZZZZZZZZZZZZZZ. AAAAAAAAAAAAAA
BBBBBBBBB
CCCCCCCCCCCCCCCC. DDDDDDDDDDDDDDDD. EEEEEEEEEEEEEEE
FFFFFFFFFFF
GGGGGGGGGGGGGGGG. HHHHHHHHHHHHHHHH. IIIIIIIIIIIIIIII.
JJJJJJJJJJJJ
KKKKKKKKKKKKKKKK. LLLLLLLLLLLLLLLL. MMMMMMMMMMMMNNNNNNNNN
OOOOOOOOOOOOOOOO. PPPPPPPPPPPPPPP
QQQQQQQQQ
RRRRRRRRRRRRRRRR. SSSSSSSSSSSSSSS
TTTTTTTTTTTTTTTT.UUUUUUUUUUUUUUUU. VVVVVVVVVVVVVVVV.

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WWWWWWWWWWWWWWWW. XXXXXXXXXXXXXXXX. YYYYYYYYYYYYYYYY.

ZZZZZZZZZZZZZZZZ.
AAAAAAAAAAAAAAAAA. BBBBBBBBBBBBBBBBB.
CCCCCCCCCCCCCCCCC.
DDDDDDDDDDDDDDDDD. EEEEEEEEEEEEEEEEE.
FFFFFFFFFFFFFFFFF.GGGGGGGGGGGGGGGGG. HHHHHHHHHHHHHHHHH.
IIIIIIIIIIIIIIIII. JJJJJJJJJJJJJJJJJ. KKKKKKKKKKKKKKKKK.
LLLLLLLLLLLLLLLLL.MMMMMMMMMMMMMMMMM. NNNNNNNNNNNNNNNNN.

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OOOOOOOOOOOOOOOOO.

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PPPPPPPPPPPPPPPPP.
QQQQQQQQQQQQQQQQQ.
RRRRRRRRRRRRRRRRR. SSSSSSSSSSSSSSSSS.
TTTTTTTTTTTTTTTTT.
UUUUUUUUUUUUUUUUU.
VVVVVVVVVVVVVVVVV.
WWWWWWWWWWWWWWWWW.
XXXXXXXXXXXXXXXXX.
YYYYYYYYYYYYYYYYY.
ZZZZZZZZZZZZZZZZZ. AAAAAAAAAAAAAAAAAA.
BBBBBBBBBBBBBBBBBB.
CCCCCCCCCCCCCCCCCC.
DDDDDDDDDDDDDDDDDD. EEEEEEEEEEEEEEEEEE.
FFFFFFFFFFFFFFFFFF.
GGGGGGGGGGGGGGGGGG.
HHHHHHHHHHHHHHHHHH. IIIIIIIIIIIIIIIIII.
JJJJJJJJJJJJJJJJJJ.
KKKKKKKKKKKKKKKKKK. LLLLLLLLLLLLLLLL
MMMMMMMM
NNNNNNNNNNNNNNNNNN.
OOOOOOOOOOOOOOOOOO. PPPPPPPPPPPPPPP
QQQQQQQQQ
RRRRRRRRRRRRRRRRRR.
SSSSSSSSSSSSSSSSSS. TTTTTTTTTTTTTTTT
UUUUUUUUU
VVVVVVVVVVVVVVVVVV.
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YYYYYYYYYY
ZZZZZZZZZZZZZZZZZZ.
AAAAAAAAAAAAAAAAAAA. BBBBBBBBBBBBBB
CCCCCCCCC
DDDDDDDDDDDDDDDDDDD.
EEEEEEEEEEEEEEEEEEE. FFFFFFFFFFFFFFFF
GGGGGGGGG
HHHHHHHHHHHHHHHHHHH.
IIIIIIIIIIIIIIIIIII. JJJJJJJJJJJJJJJJJJ
KKKKKKKKK
LLLLLLLLLLLLLLLLLLL.
MMMMMMMMMMMMMMMMMMM. NNNNNNNNNNNNNN
OOOOOOOOO
PPPPPPPPPPPPPPPPPPP.
QQQQQQQQQQQQQQQQQQQ. RRRRRRRRRRRRRR
SSSSSSSSSS
TTTTTTTTTTTTTTTTTTT.
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BBBBBBBBBBBBBBBBBBBB.
CCCCCCCCCCCCCCCCCCCC. DDDDDDDDDDDDDD
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GGGGGGGGGGGGGGGGGGGG. HHHHHHHHHHHHHH
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JJJJJJJJJJJJJJJJJJJJ.
KKKKKKKKKKKKKKKKKKKK. LLLLLLLLLLLLLLLL
MMMMMMMM
NNNNNNNNNNNNNNNNNNNN.
OOOOOOOOOOOOOOOOOOOO. PPPPPPPPPPPPPPP
QQQQQQQQQ
RRRRRRRRRRRRRRRRRRRR.
SSSSSSSSSSSSSSSSSSSS. TTTTTTTTTTTTTTTT
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VVVVVVVVVVVVVVVVVVVV.
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YYYYYYYYYY
ZZZZZZZZZZZZZZZZZZZZ.
AAAAAAAAAAAAAAAAAAAAA. BBBBBBBBBBBBBB
CCCCCCCCC
DDDDDDDDDDDDDDDDDDDDD.
EEEEEEEEEEEEEEEEEEEEE. FFFFFFFFFFFFFFFF
GGGGGGGGG
HHHHHHHHHHHHHHHHHHHHH.
IIIIIIIIIIIIIIIIIIIII. JJJJJJJJJJJJJJJJJJ
KKKKKKKKK
LLLLLLLLLLLLLLLLLLLLL.
MMMMMMMMMMMMMMMMMMMMM. NNNNNNNNNNNNNN
OOOOOOOOO
PPPPPPPPPPPPPPPPPPPPP.
QQQQQQQQQQQQQQQQQQQQQ. RRRRRRRRRRRRRR
SSSSSSSSSS
TTTTTTTTTTTTTTTTTTTTT. UUUUUUUUUUUUUU
VVVVVVVVVV
WWWWWWWWWWWWWWWWWWWWW. XXXXXXXXXXXXXXX

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YYYYYYYYYYYYYYYYYYYYY.
ZZZZZZZZZZZZZZZZZZZZZ.AAAAAAAAAAAAAAAAAAAAAA
BBBBBBBBBBBBBBBBBBBBBB.
CCCCCCCCCCCCCCCCCCCCCC. DDDDDDDDDDDDDDDDDDDDDD
EEEEEEEEEEEEEEEEEEEEEE.
FFFFFFFFFFFFFFFFFFFFFF. GGGGGGGGGGGGGGGGGGGGG
HHHHHHHHHHHHHHHHHHHHHH.
IIIIIIIIIIIIIIIIIIIIII. JJJJJJJJJJJJJJJJJJJJJJ.
KKKKKKKKKKKKKKKKKKKKKK.
LLLLLLLLLLLLLLLLLLLLLL.
MMMMMMMMMMMMMMMM
NNNNNNNNNNNNNNNNNNNNNN.
OOOOOOOOOOOOOOOOOOOOOO.
PPPPPPPPPPPPPPPPPPPP
QQQQQQQQQQQQQQQQQQQQQQ.
RRRRRRRRRRRRRRRRRRRRRR.
SSSSSSSSSSSSSSSSSSSS

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