DOMESTIC TRAVEL & EMERGENCY

RESPONSE PLAN
REX-IND-FRM-1607
Rencana Perjalanan Domestik & Tanggap Darurat

This form must be completed by employees who will travelling domestically for work reasons. A copy
should be sent to destination staff at least one (1) week prior to departure as follow:
Formulir ini harus diisi oleh karyawan yang akan melakukan perjalanan domestik untuk keperluan
pekerjaan. Salinan dokumen ini harus dikirim ke staf yang ditunjuk di tempat tujuan setidaknya satu
(1) minggu sebelum keberangkatan,sebagai berikut:

TO Chief Mine Technical Officer / KTT hendra.sebayang@vale.com

Site Notification ptvei_stm_travel-to-site@vale.com
Accommodation & Transport receptionist.stm@pangansari.co.id
CC
Health Information (PCR, Medical vale.additionalmedicalteam@ms.internationalsos.com
Risk Assessment)

DETAILS OF PERSON TRAVELLING

Name/Nama: syafwanuddin

Employer/
Perusahaan: PT.Grow Safety Indonesia Position/Posisi: Fire Instructor

Company Address/ Conventional Office, Wisma SIER Lt. 3, Jl. Rungkut Industri Raya No.10,
Alamat Perusahaan: Rungkut Tengah, Kec. Gn. Anyar, Kota SBY, Jawa Timur 60593

Mobile / Hp: 081395621551 Email: wawansyafwanuddin@gmail.com

Home Address/ Perum SDR 1 Jl.Sejahtera 1 No.70 Keputih Sukolilo Surabaya

Alamat rumah:

Medical:
Medication/ none
Pengobatan (yang sedang dijalani/diminum):

Obat Voltaren
Allergies/Alergi:

Chronic Medical History/ none

Riwayat penyakit kronis:

Next of Kin/ Arby Maulana 087864539016

Keluarga Terdekat: Tel:

Print Date: Authorised By Version Number / Date Review Date Page:

24 February 2023 Bede Evans Rev004/1 Oktober 2021 3 years 1 of 6
D:\Proposal IHT\Sumbawa Timur Mining\STM 2023\Revisi 0.1\WAWAN\2023_NEW STM-VEI DOMESTIC TRAVEL-ERP DOCUMENT.docForm/Travel/REX-IND-FRM-1607 - Domestic Travel and Emergency Response
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 DOMESTIC TRAVEL & EMERGENCY
RESPONSE PLAN
REX-IND-FRM-1607
Rencana Perjalanan Domestik & Tanggap Darurat

TRIP OUTLINE/ RINCIAN PERJALANAN

Flight from Surabaya – Lombok Praya- Bima.
Destination/
Tujuan:

Andi Awang
Contact Person at Destination/
Kontak Personil di tempat tujuan:

Date Flight No. Flight Origin Destination Depart Arrive

4 Mar 2023 FE11YJ Surabaya (SUB) Lombok (LOP) 06.00 08.05

4 Mar 2023 GRELML Lombok (LOP) Bima (BMU) 10:25 11:25

ACCOMMODATION DETAILS
Any Lestari
Jl.Lintas Lakey Kec.Huu Kab.Dompu NTB

LAND TRANSPORT
Light Vehicle will be arranged by Transportation Organizer

EMERGENCY EQUIPMENT

Map Attached: Yes X No

GSM Signal Availability: Yes X No Type: XL, Telkomsel

Satellite Phone: Yes No X #:

First Aid Kit: Yes X No

GPS Availability: Yes X No

Safety Boots & Helmet

PPE & Extra Equipment:

Print Date: Authorised By Version Number / Date Review Date Page:

24 February 2023 Bede Evans Rev004/1 Oktober 2021 3 years 2 of 6
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 DOMESTIC TRAVEL & EMERGENCY
RESPONSE PLAN
REX-IND-FRM-1607
Rencana Perjalanan Domestik & Tanggap Darurat

COVID-19 VACCINATION RECORD

Product Name Sinovac

First Dosage 9 April 2021

Date & Location

Second Dosage 7 May 2021

Date & Location

Booster Dosage
29 Jan 2022
Date & Location

COVID-19 Vaccination Card

Print Date: Authorised By Version Number / Date Review Date Page:

24 February 2023 Bede Evans Rev004/1 Oktober 2021 3 years 3 of 6
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 DOMESTIC TRAVEL & EMERGENCY
RESPONSE PLAN
REX-IND-FRM-1607
Rencana Perjalanan Domestik & Tanggap Darurat

Print Date: Authorised By Version Number / Date Review Date Page:

24 February 2023 Bede Evans Rev004/1 Oktober 2021 3 years 4 of 6
D:\Proposal IHT\Sumbawa Timur Mining\STM 2023\Revisi 0.1\WAWAN\2023_NEW STM-VEI DOMESTIC TRAVEL-ERP DOCUMENT.docForm/Travel/REX-IND-FRM-1607 - Domestic Travel and Emergency Response
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 DOMESTIC TRAVEL & EMERGENCY
RESPONSE PLAN
REX-IND-FRM-1607
Rencana Perjalanan Domestik & Tanggap Darurat

IN CASE OF EMERGENCY/ DALAM KEADAAN DARURAT

In the event of an emergency, please notify the following emergency contacts immediately/ Jika
terjadi keadaan darurat, mohon memberitahu segera kontak darurat berikut ini:

1. Hendra Sebayang, KTT 4. PT. Sumbawa Timur Mining

Tel: +62 811 499 540 PT. Vale Eksplorasi Indonesia
Sequis Tower, 29th Floor, Jl. Jend.
2. Utari Kessell, HR Sudirman Kav 71,
Tel: +62 81199912383 SCBD, Jakarta Selatan, 12190
Telp: +62 (21) 5085 7450
3. Yan Fuadi, OHS 5. Int’l SOS Alarm Center
Tel: +628122751806 Tel: +62 21 5706001
Project Membership/05APAA096282

RECOMMENDED HOSPITALS / CLINICS

Dompu Bima
RSUD Dompu RSUD Bima
Jl. Kesehatan 1, Dompu Jl Langsat 1 Rabangodu, Rasanae
Tel: +62 (373) 21118/ 21411 Bima 84113 Tel: +62 (374) 43142

Mataram, NTB Jakarta

RS Risa Sentra Medika Rumah Sakit Pondok Indah
Jl. Pejanggik No. 115, Cakranegara, Jl. Metro Duta Kav. UE
Mataram 83231 Tel: +62 (370) 632 117 Pondok Indah, Jakarta 12310 Indonesia
Tel: +62 (21) 765 7525
Denpasar, Bali Fax: +62 (21) 750 2324
RS Kasih Ibu Email: rspi@rspondokindah.co.id
Jl. Teuku Umar No 120, Bali 80114 www.rspondokindah.co.id
Tel: +62 (361) 223 036/237 016

SOS Medika Klinik Bali Singapore

Jl. By Pass Ngurah Rai 505 X Kuta, Bali Raffles Hospital Pte. Ltd.
Tel : +62 361 710505 / 720100 Address: 585 North Bridge Road #01-00,
Singapore 188770
Tel: + 65 6311 1111 (General); 6311 1555
(A&E) / +65 6311 1222 (24 hrs General
Appt)
+65 6311 1666 (IPC) / +65 9828 3784
(IPC) (mobile)

Print Date: Authorised By Version Number / Date Review Date Page:

24 February 2023 Bede Evans Rev004/1 Oktober 2021 3 years 5 of 6
D:\Proposal IHT\Sumbawa Timur Mining\STM 2023\Revisi 0.1\WAWAN\2023_NEW STM-VEI DOMESTIC TRAVEL-ERP DOCUMENT.docForm/Travel/REX-IND-FRM-1607 - Domestic Travel and Emergency Response
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 DOMESTIC TRAVEL & EMERGENCY
RESPONSE PLAN
REX-IND-FRM-1607
Rencana Perjalanan Domestik & Tanggap Darurat

MAPS

Print Date: Authorised By Version Number / Date Review Date Page:

24 February 2023 Bede Evans Rev004/1 Oktober 2021 3 years 6 of 6
D:\Proposal IHT\Sumbawa Timur Mining\STM 2023\Revisi 0.1\WAWAN\2023_NEW STM-VEI DOMESTIC TRAVEL-ERP DOCUMENT.docForm/Travel/REX-IND-FRM-1607 - Domestic Travel and Emergency Response
Plan_090417-to Huu
 DOMESTIC TRAVEL & EMERGENCY
RESPONSE PLAN
REX-IND-FRM-1607
Rencana Perjalanan Domestik & Tanggap Darurat

Print Date: Authorised By Version Number / Date Review Date Page:

24 February 2023 Bede Evans Rev004/1 Oktober 2021 3 years 7 of 7
D:\Proposal IHT\Sumbawa Timur Mining\STM 2023\Revisi 0.1\WAWAN\2023_NEW STM-VEI DOMESTIC TRAVEL-ERP DOCUMENT.docForm/Travel/REX-IND-FRM-1607 - Domestic Travel and Emergency Response
Plan_090417-to Huu