FORMULIR ASESMEN

FASILITAS LABORATORIUM TB

A. DATA UMUM/ GENERAL DATA

1. NAMA / NAME
Nama bangunan/properti
Name of building/property

2. LOKASI / LOCATION
Alamat
Address

No. telepon/email/website

Kelurahan

Kota

Provinsi

Kode Pos

Peta lokasi (Foto Satelit) yang menunjukkan akses ke lokasi, alur sirkulasi serta fungsi bangunan di
sekitarnya

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 FORMULIR ASESMEN
FASILITAS LABORATORIUM TB

3. KEPEMILIKAN / OWNERSHIP
Nama lengkap pemilik /institusi
yang dapat dihubungi/
Contact person – applicant’s name

Nomor telepon dan email kontak/

Phone & e-mail of applicant

Jabatan/posisi (pemilik, penyewa,

pengelola, arsitek, kontraktor, dll)/
Applicant’s position

Status kepemilikan bangunan &

tanah (milik sendiri, sewa, dll).
Nama orang/ institusi pemilik
bangunan. Building and site/land
ownership status
Name of owner/institution

Surat pembuktian dilampirkan (Provide letter of intent)

B. KELENGKAPAN DOKUMEN BANGUNAN/ BUILDINGS’ DOCUMENTS

1. DOKUMENTASI & PERENCANAAN BANGUNAN / DOCUMENTATION & PLANNING

Penjelasan mengenai pemeriksaan kondisi bangunan, perencanaan dan rekomendasi yang pernah
dilakukan.
Description of previous building’s assessment, planning and recommendations.

Konfirmasi pendaftar / applicant confirmation

a. Apakah bangunan sudah pernah Sudah Belum

disurvei dan dinilai kondisinya Jelaskan pelaksana dan waktu pelaksanaannya.
sebelum ini./ Building condition
assessment status

b. Dokumen gambar eksisting  Ada Tidak ada

bangunan / Jika ada, terdiri dari gambar:
Existing building documents

c. Apakah bangunan sudah memiliki Sudah Belum

rencana renovasi/pemanfaatan Jika sudah, jelaskan lingkup perencanaannya.
bangunan

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 FORMULIR ASESMEN
FASILITAS LABORATORIUM TB

Scope of Renovation plan

(perawatan, pemugaran, adaptasi,
program fungsi baru / regular
maintenance, moderate/complex
renovation, adaptation, new
function)
d. Apakah perencanaan melibatkan Ya Tidak
perencana/ planner Sebutkan nama arsitek/ tim yang terlibat.

e. Dokumen perencanaan/  Ada Tidak ada

Documents/ Drawings of Jika ada, terdiri dari dokumen perencanaan apa saja:
Renovation plan
(dok.rencana perawatan, dok.rencana
pemugaran, dok.renc.adaptasi,
doc.MEP / maintenanc doc.,
renovation doc.adaptation doc.,
Services-MEP doc)

2. LAMPIRAN HASIL DOKUMENTASI & PERENCANAAN *Jika ada / ATTACHMENT OF DOCUMENTS

(DOCUMENTATION & PLANNING) *if available.

C. KONDISI BANGUNAN & IDENTIFIKASI KERUSAKAN/ BUIILDINGS CURRENT CONDITION &

IDENTIFICATION OF BUILDING DAMAGES

1. ATAP / ROOF AREAS

Item Kerusakan / Possible Defects

Atap genteng tanah liat /  Bergeser/ melorot, Slipped,

Terracotta tiles  pecah, broken,
 retak, cracked,
 sambungan metal berkarat, corroded fixings, missing,
 bubungan tidak rapi, poor ridge capping,
 dll, etc.

Atap Metal / Metal sheet  Melorot, Loose, corroded

roofing
Besi galvanis, tembaga, seng,
alumunium (Galvanized iron,
copper, zinc sheeting, aluminum)
 berkarat, corroded fixings
 berlubang, holes
 sambungan lapuk, deteriorated patches
 penyok bekas injakan, dented by foot traffic
 air tergenang, water ponding
 terdapat bagian yang hilang, missing sections
 bukan atap asli not original roof

Talang Datar & flashing/  Besi galvanis, Galvanized iron

Gutters & flashing  colorbond – menggunakan dua jenis metal yang tisak sejenis,
colorbond, – metals incompatibility

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Talang tegak dan boks talang /
Downpipes & Rainwater heads
Perlindungan hewan liar/
Vermin Protection
Papan atap/list-plank &
talang / teritisan, sudut
pertemuan papan / Timber
fascia boards, Eaves, Barge
Board, etc
 Cerobong / Chimney
 exhaust / exhaust flues
 lubang ventilasi / air vents
 jendela dormer / dormer
vents
 menara ventilasi / dormer
windows
 ujung atap /roof
lanterns, finials
Rangka atap / Internal roof
structure
Foto-foto kondisi eksisting dilampirkan (Provide photos of existing conditions)
FORMULIR ASESMEN
FASILITAS LABORATORIUM TB
 terdapat reruntuhan/ tanaman, Full of debris or vegetation
 air menggenang, water ponding from inadequate fall
 kapasitas tidak sesuai, failed jointing
 sambungan lepas, missing sections
 ada bagian yang hilang, corroded or corroded fixings
 berkarat, berlubang, holes or splits.
 Tersumbat, Blockage
 berkarat, corroded
 kapasitas tidak sessuai, inadequate capacity
 sambungan lepas, joints failing
 pemasangan tidak benar, corroded fixings, inadequate fixings
 tekukan terlalu tajam, sharp angle bends
 tidak terhubung dengan bak control, not connected to storm
water drains
 terdapat bagian yang hilang, missing sections -all or part
 JIka terdapat penghalau burung? Any bird proofing?
 Tidak berfungsi, not working
 secara estetis mengganggu, aesthetically insensitive
 pemasangan mengaibatkan kerusakan atap. fixing causing damage
 Apakah penghalau burung diperlukan? Bird proofing needed?
 Cat mengelupas, Peeling paint
 kayu lapuk, weathered timber, rot
 kayu terlepas, split
 terdapat rayap, repainting required
 kayu membusuk, evidence of termites,
 ada yang hilang, dll missing sections, etc
 Rusak, Damaged
 ada yang hilang sebagian/ keseluruhan, missing -in parts or whole
 lapuk, rot
 berubah bentuk/ dimodifikasi modified, metal or glass missing
 Struktur kayu, lapuk, Timber structure, rot
 terdapat bagian yang hilang, missing pieces
 rangka baja, steel trusses
 terdapat bagian yang hilang, missing members
 bracing, bracing
 gording, kasau & reng, purlins, battens
 balok kuda-kuda dan balok penggantung rangka plafond beams and
ceiling hanger beams
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 FORMULIR ASESMEN
FASILITAS LABORATORIUM TB

2. ELEMEN DINDING LUAR / EXTERIOR ELEMENTS

Item Kerusakan / Possible Defects
Cat & Plesteran / Paint &  Kopong, Drummy
Render  tidak menempel, detaching
 retak, cracked
 terkikis, eroded
 megelupas, missing sections
 menggunakan cat tidak bernafas, non-breathable paints
 plesteran menggunakan semen, cement rich render patches and coatings
 lembab dan kadar garam tinggi, dampness and salt attack
 terdapat tanaman liar, ruptured by vegetation growth
 cat menggelembung, bubbling paint
 cat berlapis-lapis, multiple paint layers
 detil ornament hilang, lost details

Spesi antar bata /  Nat spesi terkikis, Open joints

Brickwork Mortar Joints  spesi tidak menempel, loose mortar
 spesi ditambal semen, hard cement mortar patching
 erosi dinding, erosion
 spesi tidak ada, missing mortar

Dinding Bata / Brickwork  Dinding terkikis, Eroded brick

Walls parapets, towers,  ada bagian yang roboh, collapsed wall sections
gables,  terdapat bata hilang, missing bricks
 pelapukan, face weathering
 retak, soiling
 lembab karena kebocoran, cracked surfaces
 lembab karena air tanah, failed or no damp proof course
 garam, perbaikan dengan semen rising damp, salt attack,
previous cement rich repairs
 tumbuh tanaman liar wild plants

Elemen Beton / Concrete  Retak, Cracking

elements: Kolom, kanopi,  lembab karena air tanah, rising damp
balkon, teritisan, teras,  lumut, moss
tangga / Columns, canopy,  tulangan berkarat, corroded iron-bars
balconies, eaves, porches,  bocor, leaking
 terdapat akar tanaman, plants roots
stairways, overhangs, etc

Batu alam / Stonework  Retak, Cracking

Granite, marble,  delaminasi, delaminating
sandstone, andesite,  efek garam, salt affected
 lapuk, weathered
 detil hilang, loose or loss of detail
 ada yang hilang, missing sections
 berjamur, biological growth
 endapan tanah, soiled by environmental pollutants
 kotoran burung, unsympathetic patches
 rembesan air, failed or no damp proof course
 sambungan/tambalan jelek, bird guano/debris

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 FORMULIR ASESMEN
FASILITAS LABORATORIUM TB

 noda korosi, corroded metal inserts

 noda coretan, graffiti
 bekas coating lama, corroded metal inserts, previous coatings applied)

Pelapis dinding / Wall  Retak, Cracking

tiling  delaminasi, delaminating
 efek garam, salt affected
 lapuk, weathered
 detil hilang, loose or loss of detail
 ada yang hilang, missing sections
 berjamur, biological growth
 endapan tanah, soiled by environmental pollutants
 kotoran burung, unsympathetic patches
 rembesan air, graffiti
 sambungan/tambalan jelek, unsympathetic paint coatings applied

Pintu (yang menghadap  Kusen/ daun pintu hilang, Missing frames and/ or sashes
luar) / Door  kaca hilang, missing glass
 kaca dicat, painted shut
 pengait daun jendela dll, sash cords
 daun pintu macet, pulleys, jammed sashes
 kaca pecah, broken glass
 dempul pecah/ hilang, defective or missing putty
 kusen dan dinding renggang, open/loose joints between
wall & timber frame
 kayu lapuk, Weather cracking in timberwork
 cat memudar deteriorated paintwork
 engsel/handle/induk kunci/espanyolet iron mongeries

Jendela / Windows  Kusen/ daun jendela hilang, Missing frames and/ or sashes
 kaca hilang, missing glass
 kaca dicat, painted shut
 pengait daun jendela dll, sash cords
 daun jendela macet, pulleys, jammed sashes
 kaca pecah, broken glass
 dempul pecah/ hilang, defective or missing putty
 kusen dan dinding renggang, open/loose joints between
wall & timber frame
 kayu lapuk, Weather cracking in timberwork
 cat memudar deteriorated paintwork
 engsel/handle/induk kunci/espanyolet iron mongeries

Parapet/ Parapets  Bunyi jika diketuk? Structurally sound?,

 Apakah ada flashing yang memadai? appropriate weather flashing?

Deretan Kolom/tiang /  Saluran air apakah mencukupi? Adequate drainage?

Colonnades  Retak di bagian lengkungan, kolom bergerak/ tidak tegak, Cracked
archways, movement of columns, lost details

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 FORMULIR ASESMEN
FASILITAS LABORATORIUM TB

 detil ornament hilang erosi metal, metal grilles erosions

Pelapis dinding/ Cladding  Kondisi pemasangan? Condition of fixings?

Sheet metal, fiber cement /
asbestos cement, cement
sheeting, timber boards,
ceramics

Tangga, balkon, balustrade  Bed correctly?, Cracks at the neck? Missing sections,
/ Stair, balcony, balusters

Jeruji, jalusi dan birai /

grills, bars & railings
Security grilles, decorative
elements
bricks, concrete, wood, metal:
iron, steel, copper, bronze,
etc.
Tata tanda / Signage  Penanda asli, Original
 ditambahkan kemudian? added later
 Efek visual & psikologis, kondisi sekarang physical and visual impact,
condition

Foto-foto kondisi eksisting dilampirkan (Provide photos of existing conditions)

3. ELEMEN DALAM DAN RUANG / INTERNAL ELEMENTS & SPACES

Item Kerusakan / Possible Defects
Lantai / Floors  Retak, Crack
Beton, kayu, ubin  miring, sloping
Concrete, timber, tiles  pecah, cracking
 tulangan korosi broken tiles, iron bars corroded

Plafon / langit-langit /
Ceiling
Anyaman & plester, GRC,
eternit, lembaran semen,
metal, kayu
Lath and plaster, fibrous
plaster, plasterboard,
cement sheet, pressed
metal, timber

Dinding / Walls
Bata, kayu, kaca, partisi

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 FORMULIR ASESMEN
FASILITAS LABORATORIUM TB

Brick, timber, glass,

partitions

Sambungan ruang /
Joinery
Pintu jendela, kusen,
architraves, bukaan,
perkakas
Doors and frames,
windows, architraves, trim,
cupboards

Finishing dinding / Wall

finishes
Plamir kapur, cat minyak/
akrilik, coating transparan,
plitur, lapis granit, dll
Limewash, oil & plastic
based paints, clear stains
and coatings, veneers,
marble, stenciled friezes,
etc.

Pintu (dalam antar
ruang) / Door
 Kusen/ daun pintu hilang, Missing frames and/ or sashes
 kaca hilang, missing glass
 kaca dicat, painted shut
 pengait daun jendela dll, sash cords
 daun pintu macet, pulleys, jammed sashes
 kaca pecah, broken glass
 dempul pecah/ hilang, defective or missing putty
 kusen dan dinding renggang, open/loose joints between
wall & timber frame
 kayu lapuk, Weather cracking in timberwork
 cat memudar deteriorated paintwork
 engsel/handle/induk kunci/espanyolet iron mongeries

Foto-foto kondisi eksisting dilampirkan (Provide photos of existing conditions)

4. AREA SITE / GROUND AREA

Item Kerusakan / Possible Defects
Saluran air, bak kontrol /  Tersumbat, Blocked drains
Drains  tidak berfungsi, defective
 rusak, broken
 tidak memadai, inadequate size
 tidak tersambung ke bak kontrol & riol kota not connected to storm water

Tanah permukaan /  Apakah menurun kea rah bangunan/ tidak? Ground falls towards the
Ground fall building causing damp
 JIka menurun menuju bangunan menyebabkan bangunan menjadi lembab

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 FORMULIR ASESMEN
FASILITAS LABORATORIUM TB

built up ground has bridged the damp proof course/ above floor level

Tanah di sekitar / Ground  Banjir setempat / Localized flooding,

areas  Genangan air / water ponding,
 Area parkir / rear parking to walls

Jalan masuk setapak / Pecah/retak, bergelombang

Pavements Material baru

Taman / Gardens  Jarak tanaman dengan bangunan seperti akar, Space between building
and adjacent trees, eg roots
 jatunya daun, falling leaves
 cabang & ranting, overhanging branches

Dinding penahan, talud /  Retak, Cracking

Retaining wall  miring, leaning
 drainase memadai, in adequate water drainage

Foto-foto kondisi eksisting dilampirkan (Provide photos of existing conditions)

5. PERALATAN PENDUKUNG / SERVICES

Item Kerusakan / Possible Defects
Mekanikal, Elektrikal, AC,  Pemasangan berlebihan, invasive fixings
Plumbing (air bersih, air  dominasi kabel secara visual, visual impact of cables
kotor, IPAL dll), lift,  jaringan sudah tidak layak expired
pemadam kebakaran,  pemipaan dan kabel, dll, ducts and pipes, leaking equipment,
compliance code impacts, corrosion staining
penangkal petir, system
sekuriti, dll
Mechanical, Electrical,
Hydraulics,
Data/Com/CCTV

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 FORMULIR ASESMEN
FASILITAS LABORATORIUM TB

D. CATATAN DAN REKOMENDASI / COMMENTS AND RECOMMENDATION

Catatan tim Asesor/

Assessor’s recommendations
a. Penilaian Kondisi Bangunan
Building’s conditions
assessment

b. Penilaian perencanaan
Bangunan
Building Planning & Heritage
Impact Assessment

c. Rekomendasi Rencana &

Program lanjutan
Recommendation for further
program and plan.

Nama penilai/ Assessor:

Tanggal penilaian/ Date Assessment: (Tanda tangan)

Nama pendaftar/ Applicant:

Diterima tanggal/ Date Received : (Tanda tangan)

Prepared by Rika Sjoekri & Arnold Sudharyanto for Subdit TB – Kemenkes RI

Adapted from Heritage Assessment Form by Ausher & PDA

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