CONTRACTOR SAFETY MANAGEMENT SYSTEM QUESTIONNAIRE

KUOSIONER SISTEM MANAJEMEN SAFETY KONTRAKTOR

Date / Tanggal :

Contractor / kontraktor :

PT Solarion Energi Alam, priority for a safe and healthy on place for employees, contractors, and neighbors. Only those contractors who have demonstrated management leadership and system resulting in good HSE performance are added to
the approved project. Please complete this CSMS form with the respective document (hardcopy and/or softcopy is preferable ). Please provide the up to date (latest) document with clear linked evidences between this form and attachment.
PT Solarion Energi Alam, memprioritaskan untuk melakukan keselamatan dan kesehatan di tempat kerjanya untuk kepentingan para karyawan, kontraktor, dan penduduk sekitar. Hanya kontraktor yang memiliki kepemimpinan dan sistem
manajemen yang menghasilkan kinerja keselamatan, kesehatan kerja dan llingkungan (K3L) yang baik yang akan diikutsertakan ke dalam proyek yang disetujui. Harap formulir CSMS ini dilengkapi dengan dokumen terkait (hardcopy and/or softcopy
lebih dianjurkan). Mohon dokumen yang dikirimkan merupakan dokumen yang terkini dilengkapi dengan sistem penandaan yang jelas pada form ini dan lampirannya.

PT Solarion Energi Alam expects that you :

- Have a documented HSE program / plan applicable to the work.
- Agree that any utilized sub-contractor will meet the requirements listed above
PT Solarion Energi Alam mengharapkan bahwa Anda :
- Memiliki dokumentasi program dan planning K3L bagi pekerjaan yang dilakukan.
- Menyetujui bahwa semua subcon yang digunakan akan memenuhi persyaratan diatas
To be considered as a contractor qualified to perform for PT Solarion Energi Alam,
you must meet the criteria at the discretion of PT Solarion Energi Alam.
Untuk dipertimbangkan sebagai kontraktor yang memenuhi syarat untuk melaksanakan
pekerjaan tertentu bagi PT Solarion Energi Alam, Anda harus memenuhi kriteria yang
ditetapkan oleh PT Solarion Energi Alam.

1. Nama Perusahaan / Company Name : Telfon Perwakilan / Contact Representatif : Email :

2. Bidang Pekerjaan / Work Field :

3. Peralatan yang Digunakan / Equipments Used :

4. Lingkup Pekerjaan / Scope of Work :

Catatan: Maka pastikan Anda melampirkan dokumen CSMS yang diminta seperti prosedur, pelatihan, dan sertifikasi sesuai dengan masing-masing jenis pekerjaan.

Note: You shall to attached CSMS documents as requested such as procedure , training , and certification related to each kind of work

Perwakilan Perusahaan,
Company Representative,

Nama / Name :
Tgl / Date :

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 NO KUESIONER / QUESTIONNAIRE EVIDENCE / LAMPIRAN BUKTI NILAI / SCORE BOBOT / WEIGHT KETERANGAN / REMARK
I KEPEMIMPINAN & KEBIJAKAN K3L / LEADERSHIP & HSE POLICY
Apakah perusahaan Anda memiliki kebijakan K3L, Salinan kebijakan K3L perusahaan terbaru yang
terdokumentasi & ditandatangani oleh pimpinan perusahaan? ditandatangani
1 0 2
Does your company have HSE Policy, documented & approved by
Copy of HSE policy Latest and Signed HSE Policy
Company Leader?
Bukti sosialisasi kebijakan HSE, daftar hadir sosialisasi, foto,
Bagaimana cara perusahaan Anda mensosialisasikan
bukti kebijakan HSE di tempat kerja
kebijakan K3L bagi pekerja dan Subkontraktor?
2 0 2
How does your company socialize the HSE policy to employee and Evidence HSE Policy socialization, attendance list, photos,
subcontractors? evidence of HSE Policy at Workplace
Bukti Keterlibatan Top Management dalam aspek HSE,
Jelaskan bagaimana keterlibatan Top Manajemen dan Senior
Prosedur MWT (Management Walkthrough), jadwal MWT dan
Manager Anda terkait dengan penerapan sistem manajemen
laporanya, Prosedur rapat HSE, daftar hadir, dan materi
3 K3L? 0 2
meeting, dll
Please, explain the involvement of your Top Management and Evidence of Top Management Involvement, HSE Meeting
Senior Manager regarding HSE management system procedure, Attendance list, Minutes of Meeting and meeting
implementation? evidence, HSE Campaigne Evidence, etc
NILAI TOTAL / TOTAL SCORE 0 6
II ORGANISASI, SUMBER DAYA, KESEHATAN DAN STANDAR / ORGANIZATION, RESOURCE, HEALTHY AND STANDARD
Apakah perusahaan anda memiliki fungsi K3L khusus?
Struktur organisasi perusahaan, bukti peran & Tanggungjawab
Bagaimana perusahaan anda memastikan setiap fungsi
HSE dalam job desc setiap fungsi
1 mempunyai peran dan tanggungjawab terhadap K3L? 0 2
Does your company have dedicated HSE function? How does yur
Organization chart, evidence of HSE roles & responsibilities in all
company ensure all function have role and responsibility against
function job description.
HSE?

Apakah perusahaan Anda memiliki HSE personil yang Riwayat pekerjaan serta sertifikasi (Depnaker / Migas)
kompeten untuk memberikan panduan dalam program K3L? pimpinan HSE personil
2 0 2
Does your company have competent HSE personnel that drive the
CV and certification (Depnaker / Migas certification) of HSE leader
HSE program?
Apakah perusahaan Anda melakukan pemeriksaan kesehatan Prosedur pengelolaan kesehatan pekerja / fit to work / MCU ,
3 secara berkala? Catatan hasil MCU dan rekapitulasi 0 2
Health Management / Fit to Work / MCU Procedure, MCU record
Does your company carry out the Medical Check Up regularly?
and recapitulation
Apakah perusahaan Anda memiliki program BPJS / asuransi
Salinan kartu BPJS / asuransi kesehatan dan kecelakaan
4 kesehatan dan kecelakaan? 0 2
Does your company have BPJS / health and accident insurance
Copy of BPJS / health and accident insurance card
program?
Apakah perusahaan anda memiliki program untuk untuk
Prosedur Higine Sanitasi,
menjaga kebersihan & kerapian dan sanitasi tempat kerja? Jika
Program terkait dengan sanitasi ditempat kerja
5 ya, Lampirkan programnya / 0 1
Hygiene Sanitasi Procedure, Evidence of industrial hygiene
Does your company have industrial hygiene program?
program

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 NO KUESIONER / QUESTIONNAIRE EVIDENCE / LAMPIRAN BUKTI NILAI / SCORE BOBOT / WEIGHT KETERANGAN / REMARK
Apakah perusahaan Anda memiliki kebijakan terkait narkoba Salinan kebijakan narkoba dan alkohol perusahaan terbaru
dan alkohol? yang ditandatangani
Bagaimana cara perusahaan Anda mensosialisasikan Bukti sosialisasi kebijakan narkoba dan alkohol, daftar hadir
6 kebijakan narkoba dan alkohol bagi pekerja? sosialisasi, foto, bukti kebijakan di tempat kerja 0 2
Does your company have policy about drugs and alcohol? Copy of drugs and alcohol Latest and Signed HSE Policy
How does your company socialize the drugs and alcohol policy to Evidence Drugs and alcohol Policy socialization, attendance list,
employee and subcontractors? photos, evidence of policy at Workplace
Bagaimana perusahaan anda mengidentifikasi peraturan dan
standar industri yang berlaku sehubungan dengan operasional Prosedur identifikasi dan evaluasi regulasi HSE
7 perusahaan Anda? 0 2
How does your company identify regulations and industrial Identifiation and evaluastion of HSE Regulations and standards
standards related to your company operations? Procedure
Bagaimana perusahaan anda memastikan bahwa peraturan
Daftar Identifikasi dan status pemenuhan peraturan-peraturan
serta standard tersebut telah diimplementasikan di
dan standar terkait perusahaan
8 operasional? 0 2
How does your company ensure those regulations and standards Status of Identifiation and evaluastion of HSE Regulations and
have been implemented at operation? standards.
NILAI TOTAL / TOTAL SCORE 0 15
III PELATIHAN & KOMPETENSI / TRAINING & COMPETENCY
Bagaimana perusahaan anda memastikan bahwa karyawan
Prosedur induksi karyawan baru, bukti induksi HSE karyawan
baru / rotasi mempunyai pengetahuan K3L dasar (kebijakan,
baru, materi induksi HSE ,Foto
1 identifikasi bahaya, tanggap darurat, dsb)? 0 2
How does your company assure that new employees / rotated Induction procedure, HSE induction material, HSE induction
employees have knowledge of basic HSE? evidence , foto
Bagaimana perusahaan anda memastikan seluruh pekerja Matriks pelatihan K3LL untuk semua pekerja dan kontraktor,
termasuk subkontraktor memiliki pengetahuan terkait dengan Prosedur HSE Training , jadwal pelatihan K3L, bukti
2 HSE dan prosedur kerja aman? pelaksanaan pelatihan K3L, sertifikat pelatihan K3L 0 2
HSE training matrix for all employees and subcontractors, HSE
how does your company ensure all employees and subcontractors
Training Procedure, Training schedule, HSE training evidence,
have knowledge about HSE and it’s safety work practices?
Certificate, etc
Apakah perusahaan anda telah melakukan identifikasi
pekerjaan-pekerjaan dan lokasi-lokasi kerja dalam operasional Daftar pelatihan khusus, program pelatihannya, bukti
yang membutuhkan pelatihan khusus untuk menangani pelatihannya, sertifikat (Contoh :pekerjaan di ketinggian,
3 potensi bahaya yang ada? (Ya/Tidak) perancah, asbes,pengleasan dll) 0 2
Jika Ya, lampirkan daftarnya dan bukti pelatihannya
Have your company identify jobs and areas where need special List of special training, it’s trainin gprogram, Training evidence,
trainings to handle it’s hazard and risks? (Yes/No) certificate (ex: Working at Height, scafolding, asbestos, welding,
if yes, provide the list and evidence etc)
NILAI TOTAL / TOTAL SCORE 0 6
IV MANAJEMEN SUBKONTRAKTOR / MANAGEMENT OF SUBCONTRACTOR
Bagaimana perusahaan Anda mengelola subkontraktor yang Prosedur Pengelolaan Subkontraktor, Prosedur CSMS,
1 dapat mendukung program K3L perusahaan? salinan CSMS 0 2
How does your company manage subcontractor for support Contractor Management Procedure, CSMS Procedure, Copy of
company HSE program? CSMS

Bagaimana perusahaan Anda memastikan bahwa Hasil evaluasi subkontraktor, dokumen kontrak yang memuat
subkontraktor memahami dan melaksanakan program K3L? aspek K3L
2 0 2
How does your company ensure that subcontractor understand and Subcontractor evaluation result, contract document that mention
implement HSE program? the HSE aspect
NILAI TOTAL / TOTAL SCORE 0 4

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 NO KUESIONER / QUESTIONNAIRE EVIDENCE / LAMPIRAN BUKTI NILAI / SCORE BOBOT / WEIGHT KETERANGAN / REMARK
V HSE DALAM DESAIN, KONSTRUKSI, DAN KOMISIONING / HSE IN DESIGN, CONSTRUCTION, AND COMISSIONING
Apakah perusahaan Anda memiliki Manual HSE dan prosedur HSE Manual , Daftar dan salinan prosedur kerja sesuai
kerja HSE sesuai dengan lingkup pekerjaan? dengan lingkup pekerjaan (Manual HSE)
1 0 3
Does your company have HSE Manual and HSE working Manual HSE, List and copy of working procedure related to the
procedure related to the scope of work? scope of work
Bagaimana Anda memastikan implementasi Manual HSE dan Sosialisasi Manual HSE & prosedur HSE dan operasi ke
2 Prosedur HSE dan Operasi di lapangan? karyawan 0 2
How do you ensure the implementation of HSE Manual and HSE Socialization HSE Manual and HSE and Operation Procedure on
and Operation Procedures on site? site
Apakah perusahaan Anda memiliki rencana Tujuan , Target
Salinan Tujuan, Target dan Program yang telah di
dan Program (KPI) K3L untuk pelaksanaan proyek yang telah
tandatangani Top Management
3 di setujui oleh top management? 0 2
Does your company have HSE Obyektive, Target dan Program
(KPI) for project execution? Does it approved by Top HSE Objective , Target dan Program signed by top management
Management?
Bagaimana perusahaan anda memantau dan meninjau Tujuan, Laporan monitoring berkala tujuan, target dan program-
4 Target & Program K3L Anda secara berkala? program HSE 0 2
How does yout company monitor and review your HSE Objective,
Report of periodic monitoring of Objective, Target & Program HSE.
Target & Program periodically
Prosedur Identifikasi Bahaya, Penilaian Resiko dan
Bagaimana perusahaan anda mengidentifikasi bahaya, menilai
Pengendalian Tambahan (HIRADC/JSA/HAZOP), Form
dan mengendalikan risiko aktivitas kerja Anda?
5 HIRADC pekerjaan 0 2
Hazard identifiction and risk assessment, and determining control
How does your company identify the hazard, assess and control
procedure, Example of HIRADC/JSA/HAZOP of operation
the risk of your work activity?
activities.
Apakah perusahaan Anda telah mengkomunikasikan Bukti sosialisasi (HIRADC/JSA/HAZOP), Daftar hadir, materi
HIRADC/JSA/HAZOP kepada pekerja terkait. sosialisasi, foto
6 0 1
Have you communicated the HIRADC/JSA/HAZOP to employees Evidence of socialization of (HIRADC/JSA/HAZOP), Attendance
and related parites? list, Socialization material(handout).
Prosedur Ijin Kerja , sosialisasi izin kerja, salinan lembar izin
Apakah perusahaan Anda memiliki prosedur Izin Kerja Aman?
7 kerja yang sudah diisi 0 2
Permit to Work Procedure, Permit to Work Socialization, Copy of
Does your company have Permit to Work procedure?
Permit to Work procedure
Apakah perusahaan Anda menyediakan APD bagi pekerja dan Prosedur APD (perawatan, penyimpanan, dll) dan Matriks
memiliki prosedur tentang APD. APD sesuai dengan lingkup pekerjaan (jenis dan spesifikasi
8 Jika ya, Lampirkan daftar APD beserta lingkup pekerjaan. sesuai standar nasional / internasional) 0 2
PPE procedure (maintenance, storage, etc.) and Matrix of PPE
Does your company provide PPE and have PPE procedure
related to the scope of work (type and specification according to
If yes, provide list of PPE and its scope of work
national / international standards)
Apakah perusahaan anda menyelenggarakan pelatihan
Laporan pelatihan APD, Daftar hadir, Materi pelatihan APD
mengenai cara penggunaan APD dengan benar?
9 0 2
Does your company provide training how to wear PPE properly? PPE Training report, Attendance list, training handout

Apakah perusahaan anda memiliki program untuk memastikan

implementasi penggunaan APD dan pemeliharaan APD Catatan/laporan inspeksi APD
10 tersebut? 0 2
Does your company havea program to ensure than PPE is
Records of PPE inspection
implemented and maintained?

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 NO KUESIONER / QUESTIONNAIRE EVIDENCE / LAMPIRAN BUKTI NILAI / SCORE BOBOT / WEIGHT KETERANGAN / REMARK
Apakah perusahaan Anda memiliki program Higiene Industri? Prosedur Higiene Industri, Laporan pengukuran Higiene
(pencahayaan, debu, suhu, ergonomi, dll) Industri
11 0 2
Does your company have Industrial Hygiene program? Industrial hygiene Procedure, Industrial Hygiene measurement
(illumination, dust, temperature, ergonomic, etc.) report
Apakah perusahaan Anda memiliki prosedur pengendalian
Prosedur pengendalian limbah B3
12 limbah B3? 0 2
Does your company have B3 procedure? B3 procedure

Bagaimana cara perusahaan Anda menangani limbah B3? (oli

Manifest limbah B3
bekas, tumpahan minyak, material B3 kadaluarsa, pelarut, dll)
13 0 1
How does your company handle hazardous waste? (used oil, oil
Manifest of hazardous waste
spill, expired hazardous material, solvent, etc.)
Apakah perusahaan Anda memiliki prosedur pengelolaan
Prosedur pengelolaan limbah domestik
14 limbah domestik? 0 2
Does your company have waste management domesticprocedure? Waste management domestic procedure

Prosedur Manajemen keselamatan Transportasi, Manajemen

Pengaturan apa yang dimiliki perusahaan Anda untuk
pencegahan kecelakaan pengangkutan?
15
Perencanaan perjalanan, Kaji risiko transportasi, Prosedur
Keselamatan mengemudi, Pelatihan keselamatan mengemudi,
Inspeksi & Pemeliharaan kendaraan , bukti implementasi
keselamatan transportasi, dll 0 2

Transportation Safety Procedure, Journey Management Plan,

What arrangement does your company have for transport incidents Transportation Risk Assessment, Safety driving training, Vehicle
prevention? maintenance and inspections, evidence of safety transportation
implementation, etc
NILAI TOTAL / TOTAL SCORE 0 29
VI MANAJEMEN PERUBAHAN / MANAGEMENT OF CHANGE
Apakah perusahaan Anda memiliki prosedur manajemen
Prosedur manajemen perubahan
1 perubahan? 0 2
Does your company have management of change procedure? Management of change procedure
Form manajemen perubahan (contoh: perubahan struktur
Bagaimana cara perusahaan Anda melakukan manajemen
organisasi perusahaan, perubahan penggunaan peralatan di
perubahan?
2 tempat kerja, dll) 0 2
Management of change form (e.g. organizational-structural change,
How does your company perform management of change?
equipment change, etc.)
NILAI TOTAL / TOTAL SCORE 0 4
VII INSPEKSI / INSPECTION
Apakah perusahaan Anda melakukan inspeksi umum tempat Bukti inspeksi K3L (min: 2 periode inspeksi), Hasil
1 kerja? Management Walkthrought 0 2
Evidence of HSE inspection (min: 2 inspection periods), Evidence
Does your company carry out the general workplace inspection?
Management Walkthrought
Bagaimana cara perusahaan Anda untuk menindak lanjuti
Laporan tindak lanjut hasil temuan
2 temuan inspeksi? 0 2
How does your company follow up the inspection findings? Report of follow up inspection finding
Apakah peralatan kerja Anda diinspeksi sebelum dikirim ke Jadwal Pemeliharan Fasilitas dan Peralatan, Bukti
3 lokasi proyek (mobilisasi)? pemeliharaan atau inspeksi peralatan 0 2
Does your company equipments inspected before sent to project Preventive Maintenance Schedule, Evidence of tools and
site area (mobilization)? equipment maintenance or inspection

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 NO KUESIONER / QUESTIONNAIRE EVIDENCE / LAMPIRAN BUKTI NILAI / SCORE BOBOT / WEIGHT KETERANGAN / REMARK
Bagaimana anda memastikan bahwa peralatan khusus
Daftar peralatan / alat ukur, Jadwal kalibrasi dan sertifikasi,
disertifikasi dan dikalibrasi oleh pihak internal atau pihak yang
Bukti sertifikasi dan kalibrasi
4 berwenang? 0 2
How does your company ensure special equipment and tools are List of tools and equipment, Certification and Calibration schedule,
certified internally or by authorized party? Evidence of certification and calibration
NILAI TOTAL / TOTAL SCORE 0 8
VIII KOMUNIKASI / COMMUNICATION
Apakah perusahaan Anda melakukan toolbox / safety talk? Daftar hadir dan materi toolbox / safety talk
1 0 2
Does your company carry out toolbox / safety talk meeting
Attendance list and materials of toolbox / safety talk meeting
program?
Bagaimana Anda menyelanggarakan Komunikasi dan Rapat
- Prosedur Komunikasi dan Rapat K3L
K3L (yang mencakup frekwensi, peserta dan topik)? Apakah
- Notulen rapat, daftar hadir, materi rapat, status tindak lanjut
mencakup tingkat Top Management sampai tingkat tenaga
2 rapat HSE 0 2
kerja di lapangan?
How do you organize HSE Communication and Meetings (covering - HSE Communication and Meetings Procedure.
the frequency, attendant and topic)? Does it cover from Top - Minutes of meetings, Attendance list, meeting handout, follow up
Management level up to employees onsite? meeting status
Apakah perusahaan Anda memiliki sarana komunikasi K3L
Contoh HSE news , HSE bulletin , HSE Alert dll
3 lainnya? (HSE news , HSE bulletin , HSE Alert dll) 0 1
Does your company have other HSE communication tool? (HSE
Example of HSE news, HSE bulletin, HSE Alert etc.
news, HSE bulletin, HSE Alert etc.)
Apakah perusahaan anda memiliki program penghargaan dan Program penghargaan dan sanksi HSE, penilaian tahunan,
4 sanksi HSE kepada pekerja terkait dengan K3L? Insentif K3L, pelaporan situasi/tindakan tidak aman terbaik. 0 1
Does your company have any reward and Punishment recognition Reward and punishment program, annual award, HSE Insentives,
program for employees related to HSE? reward for best hazard observation, etc.
NILAI TOTAL / TOTAL SCORE 0 6
IX TANGGAP DARURAT / EMERGENCY RESPONSE
Apakah perusahaan Anda memiliki prosedur tanggap darurat
Prosedur Tanggap Darurat, bukti sosialisasi prosedur tanggap
dan prosedur tersebut telah di sosialisasikan kepada seluruh
darurat ( daftar hadir, Notulen, materi sosialisasi)
1 pekerja? 0 2
Does your company have emergency procedure and this procedure Emergency system procedure, Evidence of socialization (
has it communicated to all employees?? attendance List, MOM, handout)
Apakah perusahaan anda memiliki tim tanggap darurat? Struktur Organisasi Tanggap Darurat, Program pelatihan
Apakah tim tersebut kompeten untuk melaksanakan tugas- tanggap darurat, daftar hadir, sertifikat pelatihan, Job Desc Tim
2 tugasnya?/ Tanggap Darurat 0 2
Emergency response team structure,Emergency response training
Does your company have emergency response team? Does the
program, attendance list, certificate of cometence, Emergency
team competent to carry on their tasks?
response team Job Desc
Apakah perusahaan anda telah melaksanakan latihan/simulasi
darurat secara berkala? Apakah latihan/simulasi tersebut Laporan Simulasi Tanggap Darurat, Evaluasi Simulasi
dievaluasi efektifitasnya? Apakah perusahaan anda Tanggap Darurat, Status tindaklanjut rekomendasi perbaikan
3 menindaklanjuti rekomendasi perbaikan yang terkait dengan dari simulasi tanggap darurat 0 2
latihan/simulasi tersebut?
Has it been evaluated? Have your company carry out follow up Emergency response excercise report, Evaluation of Emergency
action related to recomendation for improvement resulted from the response exercise, Status of recomendation for improvement from
simulation/excercise? the exercise
NILAI TOTAL / TOTAL SCORE 0 6

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X PELAPORAN DAN PENYELIDIKAN KEJADIAN KECELAKAAN DAN PENCEMARAN LINGKUNGAN / REPORTING AND INVESTIGATION OF INCIDENT AND ENVIRONMENTAL POLLUTION
Bagaimana perusahaan anda menyelidiki, melaporkan dan Prosedur Investigasi Insiden, Matriks Investigasi Insiden,
menindaklanjuti insiden dan kecelakaan? Metode Investigasi Insiden, Formulir Investigasi Insiden, dll
1 0 2
How does your company investigate, report and follow-up of Incident investigation procedure, Incident investigation matrix,
incident? Incident investigation form, etc
Apakah perusahaan Anda mencatat statistik kecelakaan dalam Statistik kecelakaan tiga tahun terakhir
2 3 tahun terakhir? (LTIFR, LTISR, dll) Mohon lampirkan contoh laporan investigasi kecelakaanM 0 2
Does your company record the accident statistic for last 3 years? Accident statistic report for last 3 years
(LTIFR, LTISR, etc.) Please attach example of accident investigation report
Bagaimana Anda melaporkan kejadian kepada manajemen
Anda? Bagaimana Anda mengkomunikasikan temuan / umpan- Bukti komunikasi temuan / umpan balik / pelajaran terkait
balik / pelajaran yang terkait dengan insiden kepada tenaga insiden (Daftar hadir, Notulen Rapat, foto-foto)
3 kerja Anda? 0 2
How do you report the incident to your management? How do you
Evidence of communication of finding / feedback / lesson learn of
communicate finding / feedback related to the incident to your
the related incident (Attendance List, Minute sof lmeeting, Photos)
employees?
Apakah perusahaan Anda memiliki tim investigasi yang
Daftar Tim investigasi, Sertifikat pelatihan tim investigasi
4 kompeten? 0 1
Does your company have competent investigation team? List of Invetigation team, certificate of investigation team
Apakah perusahaan anda Anda memiliki sistem pelaporan Contoh Kartu Observasi Bahaya (HOC) / STOP Card /
nyaris celaka atau situasi/tindakan tidak aman? Pengamatan Kerja Aman (PEKA) dll
5 0 1
Does your company have near miss or anomaly (unsafe action / Example of Hazard observation Card (HOC)/STOP Card/ Safe
unsafe condition) reporting system? Working Observation (PEKA), etc.
NILAI TOTAL / TOTAL SCORE 0 8
XI TINJAUAN MANAGEMEN / MANAGEMENT REVIEW
Apakah perusahaan anda mempunyai prosedur tinjauan
Procedure Management Review HSE, Daftar hadir, Notulen
manajemen terkait K3L? Lampirkan 2 kegiatan rapat tinjauan
rapat, materi rapat
1 manajemen terkait K3L 0 2
Does your company have HSE Management Review Procedure? HSE Management Review Procedure, Attendance list, Minutes of
Provide evidence of last 2 (two) Management revew meeting, meeting handout

NILAI TOTAL / TOTAL SCORE 0 2

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XII EVALUASI / EVALUATION
Apkah perusahaan Anda memiliki prosedur evaluasi K3L? Salinan prosedur evaluasi K3L
1 0 2
Does your company have HSE evaluation procedure? Copy of HSE evaluation procedure
Apakah perusahaan Anda melakukan internal audit K3L? Jadwal dan laporan hasil internal audit K3L
2 0 2
Does your company carry out HSE internal audit? Schedule and report of HSE internal audit
Apakah perusahaan Anda memiliki sertifikat sistem Salinan sertifikat ISO 45001:2018, ISO 14001: 2015, SMK3,
3 manajemen K3L dari pemerintah / badan sertifikasi? penghargaan jam kerja aman, dll 0 2
Does your company have HSE management system certification Copy certificate of ISO 45001:2018, ISO 14001: 2015, SMK3,
from government / certification agencies? reward for zero accident, etc.)
NILAI TOTAL / TOTAL SCORE 0 6
NILAI TOTAL KESELURUHAN / TOTAL SCORE OVERALL
Minimal Skor kelulusan High Risk 80 Skor Kelulusan tergantung dari
Minimal Skor kelulusan Medium Risk 70 0 100 Kebijakan HSE Client
Minimal Skor kelulusan Low Risk 60

PT. ……......................................……... HAS PASSED THE QUALIFICATION

Reviewed by, Approved by,

date…………

HSE MANAGER PROJECT MANAGER

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