MINISTRY HEALTH REPUBLIK INDONESIA

PORT HEALTH OFFICE

BANDAR UDARA INTERNASIONAL SULTAN HASANUDDIN MAKASSAR
FORMULIR PEMERIKSAAN SANITASI PESAWAT UDARA
AIRCRAFT SANITATION INSPECTION CHEK LIST

Pemilik atau Penyelenggara : .............................................. Nomor Penerbangan : ............................................

Owner or Operator Flight Number
Tanda Kebangsaan dan Pendaftaran : ............................... Tanggal/Jam : ........................................................
Marks of Natiolanity and Registration Date/Time
Berangkat dari : .................................................................. Tujuan : .................................................................
Departure From Destination

Kebersihan (Cleanliness)*
NO.
Y a n g D i p e r i k s a
Bersih Tidak Bersih
Items (Good) (Poor)

a. Lantai (Floor)..........................................................
Kabin Penumpang b. Kursi (Seats)............................................................
1.
Passenger Cabins c. Meja (Table)............................................................
d. Kantong belakang kursi (Seat-Back pocket)...........

a. Lantai (Floor)...........................................................
b. Alas duduk & Penutup (Seat & Cover)...................
Komponen Toilet
2. c. Temapt sampah (Waste bins)...................................
Toilet Compartement d. Tempat cuci tangan (Wash hand basin)..................
e. Kaca (Mirror)............................................................
a. Lantai (Floor) ...........................................................
Tempat Penyimpanan b. Alas tempat kerja (Worktop) ....................................
Makanan c. Bak cuci (Sinks) ........................................................
3. Galley d. Tempat sampah (Waste bins) ...................................
e. Ruang tempat kontainer (Trolley Stowage) ..............
Diangkat Mewah
a. Tipe toilet (Typical aircraft toilet)............................ Portable Suitable
b. Ditangani petugas khusus (Handle by spesial
personal)....................
Pembuangan Kotoran Cair*
4. c. Diangkat dalam keadaan tertutup (Enclosed during
Excreta disposal
transportation)
d. Tercecer waktu diangkat (Spillage during
transportation)................

Ditangani petugas khusus (Handle by special personal)*...............

Penanganan Penyediaan Air Power of Hydrogen (Ph)…………………………. ppm. (aircraft) ;
5.
Aircraft water supply Sisa kadar chlor (Residual Chlorire........................ ppm. (aircraft) ;
Banyaknya contoh (Number of samples).......................... (aircraft)
A. Baik (Good)
Keadaan Makanan Secara
B. Jelek (Poor) :*
6. Fisik *
C. Banyaknya contoh (Number of samples)...................................................................
Physical appearance of Food
**(sebutkan jenis makanannya): ..................................................................................
Binatang Pengganggu * Nyamuk Lalat Kecoak Tikus Lain-lain
7.
Pest Infestation Mosquitoes Flies Cockroachs Rodent Others
Tindakan pemberantasan serangga selama penerbangan (Disinsecting treatment during the flight) :
a. Nama Insektisida (Kind of insectcide)……………………………………………………………………………………………..
8.
b. Jumlah yang dipakai (Total Number) ……………………………………………………………………..gram…………………
c. Nomor tabung yang dipakai (Number of flash) ……………………………………………………………………………………
Rekomendasi dan Tindakan :
Recomendation and measures

Isilah tanda √ untuk jawaban ya, dan tanda untuk jawaban tidak
×

Cabin Crew, Sanitary Inspector,