Ek PT. PRATAMA WIDYA Tbk PERSYARATAN SUB-KONTRAKTOR ac FORMULIR PENILAIAN HS! YEDIA JASA BARANG (UNTUK VENDOR) No ‘LSCRLA Ls Nilai Deskripsi Score 1 ROYAL KRANE PERKASA, 4 Company Name 2 | Alama JL, PLN BUARAN NO92, CIKOKOL - KOTA TANGERANG 7 Company 3 | Bidang Usaha: Jasa-Konstruksi‘Pengedean- MoterialJasa Lainnya __(*) g {ine of Business Consinuction Services’Procurement of Materials Other Services (*) Pilih dengan metinghari dan bisa lebih dari satu pi Select by circled and can be more than one option 4 | Bila bidang usaha Jasa Konstruks vanz dip sah abel di bowah in When the business sector of Construction Services have been selected, please fll out the table below a ron OF CONSTRUCTION SERVICES THAT. Tipe Pekerjaan| ‘Sebutkan Nama Heat! a ‘Mention name ca [Mechanical 7 a a ff rey Pipe Line [ Rental alat berat Dipindai dengan CamScannerPT. PRATAMA WIDYA Tbk PERSYARATAN SUB-KONTRAKTOR 2021 2020 2019 Catatan kecelakaan 3 tahun terakhir: ‘Note accidents last 3 years: Pratama | FTW-SMK3-PRo-oss | —REVISI : 00 “Tel. Terbit : 22.07.2022 NO. DESCRIPTION Deskrpsi Score 5 STATISTIK SHE (SHE STATISTIC 4 Classification Fatality (meningeal), Hari Kerja Hilang Fatality (deceased), Working Day Lost ‘Memerlukan perawatan medis(Sementara tidak mampu Beker secara normal seperti iasanya Requires medical reament (While notable to work normally as usual) Memerlukan perawatan medis (Mampu Kembali bekerja seperti biasa) [ o | [Reguires medical ireatment (Able to return to work as usual) Memerlukan pertolongan pertams pada kecelakaan (P3K) Requires first aid (P3K) ‘Data Nearmisses d Nearmisses data Fatality (meninggal), Hari Kerja Hilang Fatality (deceased), Working Day Lost rerlukan perawatan medis (Sementara tidak mampu bekerja secara oral sper isa) Requires medical treatment (While notable 1 work normally as usual) ‘Memerlukan perawatan medis (Mampu kembali bekerja seperti biasa) Requires medical treatment (Able to return to work as usual) Memerlukan | longan | ma ‘kecelakaan (P3K) | Requires first aid (P3K) Data Nearmisses Nearmisses data ae ia | Fatality (deceased), Working Day Lost Memerlukan vatan medis (Sementara tidak mampu bekerja secara noma seperti bisana) 0 Requires medical treatment (While not able to work normally as usual) ‘Memerlukan perawatan medis (Mampu kembali bekerja seperti biasa) Requires medical treatment (Able fo return to work as usual) ‘Memerlukan pertolongan pertama pada kecelakaan (P3K) Requires first aid (P3K) Data Nearmisses Nearmisses data Each item must be equipped with attachments supporting data Dipindai dengan CamScannerEK PT, PRATAMA WIDYA Tbk PERSYARATAN SUB-KONTRAKTOR Pratama — | PTW-SMK3.PRo.0ss | REVISI : 00 ‘Tal Terbit: 22.07.2022 Data 3 tahun terabhir untuk Frequency Rate (FR), dengan 6 | Pa of the last 3 yours for Frequency Rate FR). hy calculation as foams 4 FR = (umlah kevelakaaihe number of accidents) x (1,000,000) Jam/Hours Jumlah Manhours//otal Manhours Frequency Hae 7 | Daua of the last 3 years for Severity Rate (SR), by calculation as follows y SR = (Mampu kembali bekerja seperti biasa / Requires medical treatment) x (1,000,000) Jamv/Hfonrs J ‘Manhours!Total Manhours ‘Apakah Perusahaan anda memiliki Kebijokan SHE? S 8 | Does your Company have SHE Policy? 7 fika Y. HE te IF VES, please siateenclose the SHE Policy? Ya, Kami memibki Kebijakan SHE (Lihat Lampiran 8) ‘Apakah Perusahaan anda memilki Program Pelatihan SHE? 9 | Does your Company have SHE Training Program? 2 4ika YA. tunjukan catatan/rekaman Pelatihan SHE IF YES, show notes'recording the SHE Training? le dan latihan d Attach training schedule and realization with training certificate and or other documentation Ya, kan melakashan training kepada para pekerja kami sesuai dengan kebutuhan pekerjaan. Diaruaranya pelathan Operator Crane, Welder, rigger, basic sea survival. (Lihat Lampiran 9) 10 liki Pe Does your Company have the SHE Responsibility? ~ ‘ika YA. scbutkan jabatan dan nama personiinya beserta sruktur organisas?? IES, please specify the postion and the name of is personnel wish organisational structure? Ya, Kami memiliki straktur organisast HSE yaitu P2K3. Dimana direktur wama adalah penangung jawad tertinggi youu Bapak Andreas Widhatama K. (Lihat Lampiran 10) Dipindai dengan CamScanneri PT. PRATAMA WIDYA Tbk PERSYARATAN SUB-KONTRAKTOR Pratama PTW-SMK3-PRO-045 REVISE : 00 ‘Tel. Terbit : 22.07.2022 11 | Apakah Perusahaan ands menempatkan petugassafety/Safety Officer pada setiap proyek? {sour Company puts Safety Officer on every projec?” ‘ka YA. sebuthonrati(perbandinganjumlah petugassafety/Safety Oficer dengan jumlah pekeriayang 4ipekerakan, dan lampirkanserfkatnys? IVES, please sate the rato ofthe numberof Safety Ofcer withthe number of workers employed and attach the crufiate? Ya, kam menempatkan safer officer berserufikat kami pala seri project wang kama kerjakan dengan rasia 1°25 (Lihat Lampiran 1) 12. | Apakah Perusahaan an aratkan sertifkasi untuk pekerjaa nisi i operator crane, welder? ‘Does your Company require certification for specific jobs such as: electricians, forklfi operator, crane ‘operator, welder? Tika aftr tenave untuk peks rtifikatnya IFYES, please attach alist of personnel fo spesifc jobs and their certificates? Ya, kami memiliki tenaga kerja khusus bersernifikat, dhantaranya adalah Operator Crane excavator horepile, nigger, welder (Lihat Lampiran 12) 13 | Apaksh Perusahaan anda memiliki peaturan Perundangan dan Prosedur SHE? ‘Does your Company have rues of Laws and Procedures SHE? ‘Tika YA. bagaimana Perusahaan anda melakukan sosialisasi kepada pekerja? Lampirkan buktisosialisasinya ISYES, how your Company to disseminate tothe workers? Attach the documentation Ya, kam memilki peraturan HSE dalam bentuk manual prosedur HSE seswat dengan undang-undang yang berlaku (Lihat Lampiran 13) 4 an anda melakukan pemeriksaan in kepada calon pekeria 2 Does your Company conduct medical examinations fo prospective field workers? Jika YA, lampirkan rekaman pemeriksaan keschatannyal IFYES, please attached the medical records! Ya, Untuk memastikan kondis keschatan pekera, kami melakukan Medical ChekUip (MCU) kepada personel ang akan bekerja di site project (Lihat Lampiran 14) ahah Perusahaan an ar 15 | Does your Company conduct toolbox meetings regularly in the work area? Sika jrkan dokumentasi pela box meeting! IFYES, please attached the toolbox meeting documentations! Ya, kami ruin metakukan toolbox mecting sebelum melakukan pekerjaan setiap hari setgp shift Dipindai dengan CamScanneri PT. PRATAMA WIDYA Tbk PERSYARATAN SUB-KONTRAKTOR Pratama | PTW-SMK3-PRO-04s | REVISI : 00 ‘Tel Terbit : 22.07.2022 Apskah Berusthaan anda melahuhan Inspehsi SHE di proyek scar uti 16 | Does your Company conduct Inspections on a regular basis SHI on the project? A.siana han, berapa kal dish an but pendukungnya? 4 {If TES. who s doing how many tines do and attached the evidences? Ya, HSE Officer selatn pengawas keselamatan rain meloknkan mypekperaltan kena setap mimggy dan Satu Pula sckali (Lihat Lamporan 16) 17 | Abshih-enusshaan ands melakuhan snk Babaya Job Safety Anais) dan Anais Resto (HIRAR)] Jum melakuken pekerjaan? Does your company conduct Hazard Identification (Job Safety Analysis) and Risk Analysis (HIRARC) before doing the work? 4Jika YA, siapa yang melakukan Analisa Resiko (HIRARC) dan bagaimana informasi ini dilakukan? Lampirk afety Anal RC yang pernah dibuat! IFES, who perform Risk Analysis (HIRARC) and how this information is done? (Attach Job Safety Analysis & HIRARC ever made!) Ya, kami selau melakukan identfikasi bahaya terhadap pekerjaan yang akan kami lakukan. Project Manager| (PMY), Supervisor, dan HSE teribatlangsung dalam idenufikasi bahaya dan resiko serta melakukan langkah- langkah penanggulangan pencegahannya agar meminimalisr terjadinya accident. (Lihat Lampiran 17) Verifikator Tanggal &2 omendasikan Tanda tangan : Dipindai dengan CamScanner