HSE FORM – SITE INDUCTION CHECKLIST

Client :

Owner :

Contractor :

Project Title : DANONE MEKARSARI PV ROOFTOP SYSTEM

Document No : MKS-1904-HF-01

Purpose : Issued For Approval

Notes : Non-Critical Document

Rev. Description Date Prepared Checked Approved

Issued for
00 03-06-20 NF RS
Approval
 JOB NO :
DOC NO : MKS-1904-HF-01
HSE SHEET
REV : 00
PAGE : 2 of 3

REVISION HISTORICAL SHEET

Rev. No. Date Description

00 03-06-2020 Issued for approval
 JOB NO :
DOC NO : MKS-1904-HF-01
HSE SHEET
REV : 00
PAGE : 3 of 3

SITE INDUCTION CHECKLIST

Project : Department/
Sub Kontraktor :
No: Nama : Posisi :
Name Position
INDUCTION TOPIC Y/N/NA INDUCTION TOPIC Y/N/NA

Kebijakan - Policy Peralatan tangan manual

 Keselamatan, Kesehatan Kerja dan Lingkungan - Manual hand tool
Corporate Safety, Health & Environment
Peralatan listrik
 Kebijakan Obat-Obatan dan Alkohol – Drug &
Electrical tool
Alcohol Policy
 Pengoperasian yang Baik - Good Operation Pemotongan dan pengelasan
Welding and cutting
Peraturan Umum - General Rule: Gerinda
 Larangan merokok ditempat kerja; larangan Grinding Safety
merokok sambil bekerja - Smoking is prohibited
in the work place; smoking is prohibited while Pneumatic tool
working. Pneumatic tool
 Larangan membawa senjata, minuman
beralkohol - Weapons & liquer are probihited Prosedur Menaikkan dan Menurunkan Muatan
 Peraturan berkendaraan: kecepatan maksimum Loading and Unloading Procedures
30km/jam; tidak boleh membawa barang-barang
B3 dan peralatan kerja di kabin penumpang - Keselamatan pengangkatan
Speed limit (30 km/h); not allow transporting Lifting safety
hazardous material and tools in passenger cabin.
Tangga Portable
 Buanglah sampah sesuai peruntukannya;.Throw
Portable Ladders
garbage in the righ place;
 Dilarang masuk / mengoperasikan alat tanpa izin Perancah
dari personnel yang bertanggung jawab - Do not Scaffolding
enter or operating equipments without permission Pekerjaan panas
by authorized personnel. Hot work
 Dilarang bersenda gurau - Horse playis
Orientasi Di Daerah Kerja
prohibited Workplace Orientation
 Pemberian tanda-tanda yang layak & standard
– Standard & proper labeling.
Regulasi Kebijakan Kehilangan APD-PPE Policy Pengenalan Lokasi Kerja Serta Penjelasan Yang
Standard APD dan Standard Stock- PPE Diperlukan
Standard Site Tours Complete With NecessaryIntroduction
Peran dan Tanggung Jawab di Wilayah Kerjanya Pengenalan Penanggung Jawab Lokasi
Role and Responsibility at the Workplace Introduction Area Responsibility Person
Bahaya-bahaya yang Potensial di Wilayah Kerjanya Lokasi Perlengkapan P3K
Potensial Hazards Around Workplace Area First Aid Facilities
Pengangkatan Secara Manual Lokasi Alat Pemadam Api Ringan
Manual Handling Fire Extinguisher Location
Bekerja pada Ketinggian Daerah Terbatas
Working at Height Restricted Acces
Bekerja Dalam Ruang Terbatas Tempat Makan dan Toilet
Work in Confined Space Cribs Room and Amenities Location
Bekerja dekat air Rute Evakuasi dan Tempat Berkumpul
Working near water Evacuation Routes and Muster Areas
Menggunakan Perkakas , Mesin-mesin dan Peralatan Fasilitas Komunikasi dan Penggunaannya
Use of Tools, Machinery and Equipment Communication Facility and It’s Use
Saya _________________________ telah menerima, mengerti dan akan mengikuti semua penjelasan topik-
topik di atas.
I have been explained, understood and will obey all of the above topics.

Tanda Tangan Karyawan: _________________________Tanggal: ______________

Signature of inducted employee Date

Nama dan Tanda Tangan Petugas yang memberikan Induksi / Inducted By:

Nama: ____________________ Tanda Tangan : ______________________Tanggal :________________

Nama Signature Date