IZIN KERJA AREA TINGGI / DILUAR

WORK PERMIT for ALOFT / OUTBOARD

M/T Pelabuhan Tanggal

/ Port: / Date:

Nama / Name of person

Lokasi pekerjaan /
Location of work

Jenis pekerjaan /
Description of work

YES/NO Initials

Apakah pekerjaan yang dilakukan menggunakan tangga tanpa

kurungan? / Is the work using cageless ladder ?

Apakah sudah mendapat izin dari Mualim I/Kepala Kamar

Mesin? / Has the permission from Chief Officer/Chief Engineer
been gotten ?

Sudahkah power supplies diisolasikan ? / Have power supplies been

isolated ?

Sudahkah semua bahaya dihilangkan ? / Any other hazards eliminated

?

Sudahkah pekerja dilengkapi dengan ikat pinggang pengaman,

helm, seragam, sepatu pelindung, dan sarung tangan? / Has person
been provided with safety belt, helmet, uniform, safety shoes, and
gloves?

Sudahkah pekerja diinstruksikan prosedur keselamatan ? / Has person

been instructed in safety procedures ?

Apakah lifebuoy siap digunakan ? / Is life buoy is ready for use ?

Sudahkah perwira jaga diinformasikan ? / Has watch officer been

informed ?

Sudahkah masinis jaga diinformasikan ? / Has watch engineer been

informed ?

Jam kerja dimulai / Time work C/O or 1/E :

commenced:

Jam kerja selesai / Time work MASTER :

completed :

Prepared by, Approved by, Acknowledge by,

______________ _______________ ________________

JSKS-SHQE FORM-JP-12-08-V(1/1) / 1 /
2012.12.04