STATUS

ISSUE
NO ANOMALY CASES REF. NO NEAR MISS CASES
 STATUS OF ANOMALY & NEARMISS REPORT
HSE DEPARTMENT PT. ……

RAISED BY
LOCATION
REF. NO NAME DATE TIME
 CLOSE - OUT ACKNOWLEDGEMENT
REMARKS
NAME DATE TIME
 PERFORMANCE ANOMALY PT. …..
JAKARTA HQ
MONTH TOTAL OPEN CLOSE REMARKS
January 0 0 0
February 0 0 0
March 0 0 0
April 0 0 0
May 0 0 0
June 0 0 0
July 0 0 0
August 0 0 0
September 0 0 0
October 0 0 0
November 0 0 0
December 0 0 0

JAKARTA HQ

1 1
0.9 0.9
0.8 0.8
0.7 0.7
0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0
ry ry il ly t r er r r ry ry ch
ch r ay ne us be be be
ua ru
a ar Ap M Ju Ju g ob ua r ua ar
an eb M Au em ct ve
m
ce
m
Ja
n
eb M
J F pt O o e F
Se N D
TOTAL OPEN CLOSE

AREA/REGONAL …
MONTH TOTAL OPEN CLOSE REMARKS
January 0 0 0
February 0 0 0
March 0 0 0
April 0 0 0
May 0 0 0
June 0 0 0
July 0 0 0
August 0 0 0
September 0 0 0
October 0 0 0
November 0 0 0
December 0 0 0

AREA/REGONAL …

1 1
0.9 0.9
0.8 0.8
0.7 0.7
0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0
ry il st r er r r
ry ch r ay ne ly
be be be ar
y
ar
y ch
ua ru
a ar Ap M Ju Ju gu m ob u u ar
an eb M Au te ct v e m em an br M
J F p O o ec J Fe
Se N D
TOTAL OPEN CLOSE

AREA/REGONAL …
MONTH TOTAL OPEN CLOSE REMARKS
January 0 0 0
February 0 0 0
March 0 0 0
April 0 0 0
May 0 0 0
June 0 0 0
July 0 0 0
August 0 0 0
September 0 0 0
October 0 0 0
November 0 0 0
December 0 0 0

AREA/REGONAL …

1 1
0.9 0.9
0.8 0.8
0.7 0.7
0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0
ry ry ch ril ay ne ly st r er er er ry ry ch
a ua ar Ap Ju u be ob b b ua ua ar
nu r M Ju g m ct em m r
Ja eb M Au pt
e
O v ce Ja
n
eb M
F o e F
Se N D
TOTAL OPEN CLOSE
0.2 0.2
0.1 0.1
0 0
y y ch ril ay e
ul
y
us
t r r r r ry ry ch
u ar u ar ar Ap M un J g be o be be be ua ua ar
r J m ct em m r
an eb M Au te ce Ja
n
eb M
J F p O ov e F
Se N D
TOTAL OPEN CLOSE
CE ANOMALY PT. …..
AREA/REGIONAL …..
MONTH TOTAL OPEN CLOSE REMARKS
January 0 0 0
February 0 0 0
March 0 0 0
April 0 0 0
May 0 0 0
June 0 0 0
July 0 0 0
August 0 0 0
September 0 0 0
October 0 0 0
November 0 0 0
December 0 0 0

AREA/REGIONAL …..

1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
ry y il ly st r r r r
ar ch r ay ne be be be be
a ar Ap M Ju Ju gu
nu br
u
M Au em ct
o
em em
Ja Fe pt O ov ec
Se N D
TOTAL OPEN CLOSE

AREA/REGONAL …
MONTH TOTAL OPEN CLOSE REMARKS
January 0 0 0
February 0 0 0
March 0 0 0
April 0 0 0
May 0 0 0
June 0 0 0
July 0 0 0
August 0 0 0
September 0 0 0
October 0 0 0
November 0 0 0
December 0 0 0

AREA/REGONAL …

1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
y y il ly t r er r r
ar ar ch r ay ne us be be be
u u ar Ap M Ju Ju g ob
an br M Au tem ct e m e m
J Fe p O ov ec
Se N D
TOTAL OPEN CLOSE

AREA/REGONAL …
MONTH TOTAL OPEN CLOSE REMARKS
January 0 0 0
February 0 0 0
March 0 0 0
April 0 0 0
May 0 0 0
June 0 0 0
July 0 0 0
August 0 0 0
September 0 0 0
October 0 0 0
November 0 0 0
December 0 0 0

AREA/REGONAL …

1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
y il t r er r r
ry ar ch r ay ne ly us be be be
nu
a u ar Ap M Ju Ju g ob
br M Au em ct em em
Ja Fe pt O ov ec
Se N D
TOTAL OPEN CLOSE
0.2
0.1
0
y il t r er r r
ry ar ch r ay ne ly us be be be
nu
a u ar Ap M Ju Ju g ob
br M Au em ct em em
Ja Fe pt O ov ec
Se N D
TOTAL OPEN CLOSE

Prepared By Acknowledge By

HSE Coordinator HSE Manager

 DAY LOST REP
JAKARTA HQ
DAY LOST
NO MONTH ACCIDENT
SICK LEAVE PERMISSION ABSEN
(Lost Max. 1 Days)
1 JANUARY 0 0 0 0 0
2 FEBRUARY
3 MARCH
4 APRIL
5 MAY
6 JUNE
7 JULY
8 AUGUST
9 SEPTEMBER
10 OCKTOBER
11 NOVEMBER
12 DECEMBER

AREA/REGIONAL …..
DAY LOST
NO MONTH ACCIDENT
SICK LEAVE PERMISSION ABSEN
(Max.2 Days)
1 JANUARY
2 FEBRUARY
3 MARCH
4 APRIL
5 MAY
6 JUNE
7 JULY
8 AUGUST
9 SEPTEMBER
10 OCKTOBER
11 NOVEMBER
12 DECEMBER

AREA/REGIONAL …..
DAY LOST
NO MONTH ACCIDENT
SICK LEAVE PERMISSION ABSEN
(Max.2 Days)
1 JANUARY
2 FEBRUARY
3 MARCH
 4 APRIL
5 MAY
6 JUNE
7 JULY
8 AUGUST
9 SEPTEMBER
10 OCKTOBER
11 NOVEMBER
12 DECEMBER

AREA/REGIONAL …..
MONTH DAY LOST
NO ACCIDENT
SICK LEAVE PERMISSION ABSEN
(Max.2 Days)
1 JANUARY 0 0 0 0 0
2 FEBRUARY 0 0 0 0 0
3 MARCH 0 0 0 0 0
4 APRIL 0 0 0 0 0
5 MAY 0 0 0 0 0
6 JUNE 0 0 0 0 0
7 JULY 0 0 0 0 0
8 AUGUST 0 0 0 0 0
9 SEPTEMBER 0 0 0 0 0
10 OCKTOBER 0 0 0 0 0
11 NOVEMBER 0 0 0 0 0
12 DECEMBER 0 0 0 0 0
DAY LOST REPORT
AREA/REGIONAL …..
DAY LOST
ACCIDENT NO MONTH
SICK LEAVE PERMISSION ABSEN
( > 2 Days )
0 1 JANUARY
2 FEBRUARY
3 MARCH
4 APRIL
5 MAY
6 JUNE
7 JULY
8 AUGUST
9 SEPTEMBER
10 OCKTOBER
11 NOVEMBER
12 DECEMBER

AREA/REGIONAL …..
DAY LOST
ACCIDENT NO MONTH
SICK LEAVE PERMISSION ABSEN
( > 2 Days )
1 JANUARY
2 FEBRUARY
3 MARCH
4 APRIL
5 MAY
6 JUNE
7 JULY
8 AUGUST
9 SEPTEMBER
10 OCKTOBER
11 NOVEMBER
12 DECEMBER

AREA/REGIONAL …..
DAY LOST
ACCIDENT NO MONTH
SICK LEAVE PERMISSION ABSEN
( > 2 Days )
1 JANUARY
2 FEBRUARY
3 MARCH
 4 APRIL
5 MAY
6 JUNE
7 JULY
8 AUGUST
9 SEPTEMBER
10 OCKTOBER
11 NOVEMBER
12 DECEMBER

DAY LOST
ACCIDENT
1
( > 2 Days ) 0.9
0 0.8
0 0.7
0 0.6
0 0.5
VALUE
0.4
0
0.3
0 0.2
0 0.1
0 0
0 Y IL LY
Y H AY E ST R R R R
AR AR C R M N
JU U BE BE BE BE
0 U U AR AP JU G O
N BR M MONTH AU TE
M
KT VE
M EM
0 JA EC
FE P C O
SE O N D
0
SICK LEAVE PERMISSION ABSEN ACCIDENT (Max.2 Days) ACCIDENT ( > 2 Days )
AY LOST
ACCIDENT ACCIDENT
(Max.2 Days) ( > 2 Days )

AY LOST
ACCIDENT ACCIDENT
(Max.2 Days) ( > 2 Days )

AY LOST
ACCIDENT ACCIDENT
(Max.2 Days) ( > 2 Days )
 ST R R R R
U BE BE BE BE
G M O M EM
AU TE KT VE
P C O EC
SE O N D
Max.2 Days) ACCIDENT ( > 2 Days )
 HSE PERFORMA
JAKARTA HQ
Description
MONTH REMARKS
AC IC F LTI R MTC FA NM AN ML DL MED

Jan 0 0 0 0 0 0 0 0 0 0 0 0
Feb
March
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec

AREA/REGIONAL …..
Description
MONTH REMARKS
AC IC F LTI R MTC FA NM AN ML DL MED

Jan 2 0 0 0 0 0 0 1 5 0 0 0
Feb
March
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec

AREA/REGIONAL …..
Description
MONTH REMARKS
AC IC F LTI R MTC FA NM AN ML DL MED

Jan 0 0 0 0 0 0 0 0 1 0 0 0
Feb
March
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec

AREA/REGIONAL …..
Description
MONTH REMARKS
AC IC F LTI R MTC FA NM AN ML DL MED

Jan 0 0 0 0 0 0 0 0 0 0 0 0
Feb
March
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec

AREA/REGIONAL …..
Description Target:
MONTH 0%
AC IC F LTI R MTC FA NM AN ML DL MED
Accident
50
Jan 2 1 0 0 0 0 0 1 50 0 6 1 0
Feb 0 0 0 0 0 0 0 0 0 0 0 0 0 45
March 0 0 0 0 0 0 0 0 0 0 0 0 0
40
Apr 0 0 0 0 0 0 0 0 0 0 0 0 0

VALUE
May 0 0 0 0 0 0 0 0 0 0 0 0 0 35
Jun 0 0 0 0 0 0 0 0 0 0 0 0 0
30
Jul 0 0 0 0 0 0 0 0 0 0 0 0 0
Aug 0 0 0 0 0 0 0 0 0 0 0 0 0 25
Sept 0 0 0 0 0 0 0 0 0 0 0 0 0
20
Oct 0 0 0 0 0 0 0 0 0 0 0 0 0
Nov 0 0 0 0 0 0 0 0 0 0 0 0 0 15
Dec 0 0 0 0 0 0 0 0 0 0 0 0 0
10

Note : 5
AC : Accident Case R : Restricted Work Days Case NM : Near Miss Case
0
F : Fatality MTC : Medical Treatement Case AN : Anomaly Case
LTI : Lost Time Injury FA : First Aid Case ML : Material Lost
DL : Days Lost MED : Major Environmental Damage IC : Icident Case

Prepared By, Acknowledged By,

Yudi Defitra Robert Manurung
HSE Coordinator HSE Manager
E PERFORMANCE
AREA/REGIONAL …..
Description
MONTH
AC IC F LTI R MTC FA NM AN ML DL MED

Jan 0 1 0 0 0 0 0 0 44 0 6 1
Feb
March
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec

AREA/REGIONAL …..
Description
MONTH
AC IC F LTI R MTC FA NM AN ML DL MED

Jan 0 0 0 0 0 0 0 0 0 0 0 0
Feb
March
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec

AREA/REGIONAL …..
Description
MONTH
AC IC F LTI R MTC FA NM AN ML DL MED

Jan 0 0 0 0 0 0 0 0 0 0 0 0
Feb
March
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec

HSE PERFORMANCE GRAFIC

50

45

40
VALUE

35

30

25

20

15

10

0 MONTH
Jan Feb March Apr May Jun Jul Aug Sept Oct Nov Dec
AC IC F LTI R MTC FA NM AN ML DL MED
REMARKS

REMARKS

REMARKS
Oct Nov Dec
JAKARTA HQ
PT. TELEKOMUNIKASI SELULAR
NO DATE/MONTH/YEAR
MANPOWER HOURS WORKED OVERTIME
1 JANUARY 35 5523 0
2 FEBRUARY
3 MARCH
4 APRIL
5 MAY
6 JUNE
7 JULY
8 AUGUST
9 SEPTEMBER
10 OCKTOBER
11 NOVEMBER
12 DECEMBER

AREA/REGIONAL …..
PT. TELEKOMUNIKASI SELULAR
NO DATE/MONTH/YEAR
MANPOWER HOURS WORKED OVERTIME
1 JANUARY 123 30336 4159
2 FEBRUARY
3 MARCH
4 APRIL
5 MAY
6 JUNE
7 JULY
8 AUGUST
9 SEPTEMBER
10 OCKTOBER
11 NOVEMBER
12 DECEMBER

AREA/REGIONAL …..
PT. TELEKOMUNIKASI SELULAR
NO DATE/MONTH/YEAR
MANPOWER HOURS WORKED OVERTIME
1 JANUARY 36 8573 1574
2 FEBRUARY
3 MARCH
4 APRIL
5 MAY
6 JUNE
 7 JULY
8 AUGUST
9 SEPTEMBER
10 OCKTOBER
11 NOVEMBER
12 DECEMBER

PT. TELKOMUNIKASI SELULAR

DATE/MONTH/YEAR NUMBER
NO
MANPOWER HOURS WORKED OVERTIME
1 JANUARY 251 63216 6984
2 FEBRUARY 0 0 0
3 MARCH 0 0 0
4 APRIL 0 0 0
5 MAY 0 0 0
6 JUNE 0 0 0
7 JULY 0 0 0
8 AUGUST 0 0 0
9 SEPTEMBER 0 0 0
10 OCKTOBER 0 0 0
11 NOVEMBER 0 0 0
12 DECEMBER 0 0 0

SUB.CONTRACTOR
DATE/MONTH/YEAR NUMBER
NO
MANPOWER HOURS WORKED OVERTIME
1 JANUARY 56 20160 0
2 FEBRUARY 0 0 0
3 MARCH 0 0 0
4 APRIL 0 0 0
5 MAY 0 0 0
6 JUNE 0 0 0
7 JULY 0 0 0
8 AUGUST 0 0 0
9 SEPTEMBER 0 0 0
10 OCKTOBER 0 0 0
11 NOVEMBER 0 0 0
12 DECEMBER 0 0 0
I SELULAR SUB.CONTRACTOR
TOTAL MANPOWER HOURS WORKED OVERTIME TOTAL
5523 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

I SELULAR SUB.CONTRACTOR
TOTAL MANPOWER HOURS WORKED OVERTIME TOTAL
34495 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

I SELULAR SUB.CONTRACTOR
TOTAL MANPOWER HOURS WORKED OVERTIME TOTAL
10147 25 9000 0 9000
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0

TOTAL PT. INDO STRAITS

70200 70000
0
60000
0
0 50000

VALUE
0
0 40000
0
0 30000
0
20000
0
0 10000
0
0
Y Y H IL AY E
LY ST R
AR AR C R M N
JU U BE
U U AR AP JU G M
JA
N BR M MONTH AU E K
FE E PT C
O
TOTAL MANPOWER HOURS WORKED S
OVERTIME

20160
0
0 SUB.CONTRACTOR
0
0 25000
0
0 20000
VALUE

0
0 15000
0
0
10000
0
5000

0
Y Y H IL AY LY E ST R
AR AR C R M JU
N U BE
U U AR AP JU G M
N BR M MONTH AU E
JA PT
FE MANPOWER HOURS WORKED
SE
OVERTIME O
 TOTAL HOURS WORKED AT PT………………
AREA/REGIONAL …..
PT. TELEKOMUNIKASI SELULAR
NO DATE/MONTH/YEAR
MANPOWER HOURS WORKED OVERTIME
1 JANUARY 21 6873 52
2 FEBRUARY
3 MARCH
4 APRIL
5 MAY
6 JUNE
7 JULY
8 AUGUST
9 SEPTEMBER
10 OCKTOBER
11 NOVEMBER
12 DECEMBER

AREA/REGIONAL …..
PT. TELEKOMUNIKASI SELULAR
NO DATE/MONTH/YEAR
MANPOWER HOURS WORKED OVERTIME
1 JANUARY 7 2604 0
2 FEBRUARY
3 MARCH
4 APRIL
5 MAY
6 JUNE
7 JULY
8 AUGUST
9 SEPTEMBER
10 OCKTOBER
11 NOVEMBER
12 DECEMBER

AREA/REGIONAL …..
PT. TELEKOMUNIKASI SELULAR
NO DATE/MONTH/YEAR
MANPOWER HOURS WORKED OVERTIME
1 JANUARY 29 9307 1199
2 FEBRUARY
3 MARCH
4 APRIL
5 MAY
6 JUNE
 7 JULY
8 AUGUST
9 SEPTEMBER
10 OCKTOBER
11 NOVEMBER
12 DECEMBER

PT. INDO STRAITS

AY NLY E ST R R R R
JU JU U BE BE BE BE
G M O M M
MONTH AU E KT VE E
E PT C O EC
HOURS WORKED S
OVERTIME O N D

SUB.CONTRACTOR

AY LYN
E ST R R R R
M JU JU U BE BE BE BE
G E M TO M M
MONTH AU
PT
K VE E
C O EC
R HOURS WORKED
SE
OVERTIME O N D
PT………………
AREA/REGIONAL …..
ULAR SUB.CONTRACTOR
NO
TOTAL MANPOWER HOURS WORKED OVERTIME TOTAL
6925 6 2160 0 2160 1
0 0 2
0 0 3
0 0 4
0 0 5
0 0 6
0 0 7
0 0 8
0 0 9
0 0 10
0 0 11
0 0 12
0

ULAR SUB.CONTRACTOR
TOTAL MANPOWER HOURS WORKED OVERTIME TOTAL
2604 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0

ULAR SUB.CONTRACTOR
TOTAL MANPOWER HOURS WORKED OVERTIME TOTAL
10506 4 1440 0 1440
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
AREA/REGIONAL …..
PT. TELEKOMUNIKASI SELULAR SUB.CONTRA
DATE/MONTH/YEAR
MANPOWER HOURS WORKED OVERTIME TOTAL MANPOWER
JANUARY 0 0 21
FEBRUARY 0
MARCH 0
APRIL 0
MAY 0
JUNE 0
JULY 0
AUGUST 0
SEPTEMBER 0
OCKTOBER 0
NOVEMBER 0
DECEMBER 0
 SUB.CONTRACTOR
HOURS WORKED OVERTIME TOTAL
7560 0 7560
0
0
0
0
0
0
0
0
0
0
0
 HSE PERFORMANCE STATISTIC

PT. TELKOMUNIKASI SELULAR

TARGET : ZERO ACCIDENT CASE

CATEGORY
NO LOCATION
AN NM AC MTC R LTI
1 JAKARTA HQ 0 0 0 0 0 0
2 AREA/REGIONAL…. 0 0 0 0 0 0
3 AREA/REGIONAL…. 0 0 0 0 0 0
4 AREA/REGIONAL…. 0 0 0 0 0 0
5 AREA/REGIONAL…. 0 0 0 0 0 0
6 AREA/REGIONAL…. 0 0 0 0 0 0
7 AREA/REGIONAL…. 0 0 0 0 0 0
8 AREA/REGIONAL…. 0 0 0 0 0 0

Total 0 0 0 0 0 0
Cummulative Cases From…
0 0 0 0 0 0

Organ Area Injury

1. Head/Kepala 0 Man hours on …….
2. Eye/Mata 0 F : Fatality freq.
3. Hand/Tangan 0 LTI : Lost Time Injury freq.
4. Finger/Jari tangan 0 R : Restricted work days
5. Body/Badan 0 cases Freq.
6. Foot/Kaki 0 MTC : Medical treatment
7. Toe/Jari kaki 0 cases Freq.
8. Others 0 AC : Accident freq.
NM : Nearmiss freq.
Work Causing Ijury MED : Major environment
damage freq.
AN : Anomaly freq.
IC : Incident freq.

Total Works Days Without LTI Free = …. days

Cummulative of LTI free per ….(diisi bulan) = …. days

EVALUATION OBJECTIVE ANDTARGET

 Period Rev. 00

Jan-08

Y
F IC MED
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 0 0

0 0 0

Cummulative
(isi Periode)
90,360 90,360
0 0
0 0

0 0

0 0
0 0
0 0

0 0
0 0
0 0

ee = …. days
diisi bulan) = …. days