4 Daily Safetyman

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PT.

NINDYA KARYA ( PERSERO )


DAILY SAFETYMAN REPORT

Date :
Project : EPC Facilty GS Upgrade Balam GS, Benar GS, Menggala GS, Pinang GS
Location :
SR Number :
Job Description :
Man Power : Staff : Person's Non Staff : Person's

WORK PERMIT AND OTHER DOCUMENT ON JOB SITE


HOT WORK CONFINED EXCAVATION HOT LINE SUPERVISOR TAILGATE TMP COLOR
Description GPTW SOP PPHA / JSA PERMIT SPACE PERMIT PERMIT CHECKLIST MEETING CHECKLIST CODE TAG
VALID
AVAILABLE/ NOT GOOD
N/A

LIGHT VEHICLE, BUS, AND EQUIPMENT ON JOB SITE


COMMENTARY ELECTRICAL HOUSE
Description SIO PERMIT SILO PTI SEAT BELT P3K FIRE EX TIRES/ BAN
DRIVE / LAMP KEEPING
VALID
AVAILABLE/ NOT GOOD
N/A

PERSONAL PROTECTIVE EQUIPMENT CONDITION


HAND SAFETY SAFETY SAFETY WELDING WELDING WELDING DUST SAFETY
Description UNIFORM EAR PLUG FACE SHIELD
GLOVE GLASES SHOES HELMET APRON SLEEVE CUP MASKER VEST
Good
Not Good
N/A

KM DRIVEN RECORD
LIGHT DUMP FOCO
Description BUS CRANE TRUCK TRAILER WATER TRUCK FUEL TANK OTHERS
VEHICLE TRUCK TRUCK
Jumlah

KM Start

KM Finish

TOTAL KM

OPERATING HOURS RECORD

WELDING MOTOR COMPACTO


Description DOZER BACK HOE EXCAVATOR CRANE COMPRESSOR OTHERS
MACHINE GRADER R

Jumlah
Start
Finish
TOTAL HOURS

FINDING ON JOB SITE


NO FINDING ACTION TAKEN PIC DUE DATE STATUS

Reported by, Acknowledge by, Recorded by,

HESMAN SUPERVISOR CONSTRUCTION HES ADMINISTRATION


NB : Isilah Form ini sesuai dengan kondisi sebenarnya di lapangan guna untuk perbaikan kedepannya
: Dapatkan temuan ( Not Good ) di checklist kolom diatas, dan uraikan temuan tersebut di kolom Paling bawah
: Selalu uraikan setiap hari temuan yang sama sampai pada akhirnya Status" diganti dari " Open " menjadi "close"
: Pastikan sejalan antara Daily saftyman ini dengan form Inspection Firex, P3K, Housekeeping dan PPE

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