WORK PERMIT / IZIN KERJA

NO:
TO BE FILLED IN BY DEPARTMENT'S OSH UNIT
Diisi oleh K3 Departemen
Working in hazardous area Working with fire and/or The works are Working on Height
and in confined space explosion hazard considered need written communication
Bekerja di area berbahaya/ruang tertutup/terbatas Bekerja dg api/bahaya ledakan Bekerja dimana diperlukan komunikasi secara tertulis Bekerja di ketinggian

Department : Building : Equipment: This W/P is valid for : ……. Days

Departemen/ dimana pekerjaan mau dilakukan Gedung/lokasi Peralatan yang akan dikerjakan W/P ini berlaku selama............. Hari

Scope of work: Emergency / break down Planned work

Cakupan pekerjaan Pekerjaan yang sifatnya emergency Pekerjaan yang direncanakan
Tools to be used: Jack hammer / welding machine / gas cutting / grinding / radiographic
Certificate for tools necessary: Yes/ No
Working height ( approx): above 1 m / above 2 m/ above 5 m/ above 10 m
Scafolding required: Yes/ No
Work group / contractor who do the work Responsible person to get the work done / W.G Leader/Attendant Authorized person to do the work/entrant

Group / Kontraktor yang melakukan pekerjaan Nama Orang yang melaksanakan pekerjaan/mengawasi Orang yang melakukan pek/yang masuk C.Space

Name of originator: Signature: Department :

Nama yang memberi ijin kerja Tandatangan Departemen pemberi kerja
Possible Hazard Lack of 02 / kekurangan oksigen Toxic Gas / gas beracun Mechanical / mekanis
Kemungkinan Combustible gas/gas mudah terbakar Toxic Vapor / uap beracun Temperature / temperatur
Bahaya Combustible vapor/uap mudah terbakar Chemical contact / terkena bahan kimia Engulfment / tertelan
Combustible dust/ debu mudah terbakar Electrical Hazard / bahaya listrik Entrapment / terperangkap

A. Safety Meassure Before the Work done / Tindakan Safety sebelum pekerjaan dimulai
1. Stop Equipment ( Describe ) = Stop mesin / peralatan , (Jelaskan) -
2. Flushing & cleaning = Pembilasan dan pembersihan
3. Blind / disconnect any pipe = Tutup / putuskan hubungan ke setiap pipa Process Isolation form No. :
4. Necessary to make free of Electric power = Perlukah memutuskan hubungan listrik Power Isolation form No. :
5. Measures against Radioactive Hazards = Pencegahan terhadap bahaya radio aktif Nomor formulir isolasi

6. Necessity to isolate the work site = Perlu mengamankan mengisolasi lokasi kerja
7. Ventilation = Pembilasan dan ventilasi Note : must for confined space job
8. Measure against ignition / fire = Pencegahan terhadap bahaya terbakar.
9. Prepare for Environment Meassures = Siapkan tindakan untuk lingkungan Inform P2K3
10. Further Meassure / Extra Meas sure = Tindakan la i n / tindakan tambahan
TEST TAKEN TLV/NAB TIME RESULT TEST TAKEN TLV/NAB TIME RESULT
11. Gas Analysis /Analisa gas
% of O2 19.5-21% CS2 10 ppm
Combustible gas < 10%LEL NH3 25 ppm
Initial tester / orang yang menganalisa
H2 S 10 ppm OTHERS
12. Frequency of testing 30 mins / 1 hr / 2 hr / 4 hr / Continuous
B. Safety Measure During the Work Done / Tindakan Safety pada saat pekerjaan berlangsung
1. Ventilation = Ventilasi Note : must for confined space job
2. Use low voltage electrical equipment, 24 VOLT = Gunakan peralatan listrik dengan tegangan rendah, 24 VOLT
3. Use the gas mask (Air line gas mask) if concentration > 10 ppm = Gunakan masker gas (udara) jika konsentrasi >10 ppm
4. Chemical resistant Clothing, Glove, Glasses = Pakaian anti bahan kimia, sarung tangan, kaca mata
5. Use Full body harness &Rope = Gunakan pengaman tubuh sepenuhnya dan tali
6. Attendant / Rescuer / Safety man required = Pengamatan / Penyelamatan / personil safety diperl must for confine job
7. Special tools during the work done = alat khusus selama pekerjaan berlangsung
8. Measures against fire = Tindakan terhadap api (Hydrant, Fire Extinguisher)
9. Rescue equipment = Peralatan penyelamatan Ambulence/Fire truck/ Air line masker/O2 cyl Note: must for confine job
10. Continuous monitoring working condition / pe mantauan kontinyu kondisi kerja
11. Safety Coordinator /Koordinator Safety Name / Nama Telp.
12. Environment Measure during the work = Langkah-langkah pengamanan terhadap selama pekerjaan berlangsung

Name who give clearance Time to start (date/time) Clearance given after control all measures
Nama yang memberi kan ijin Waktu mulai (tgl/jam) Ijin diberikan setelah kontrol semua tindakan pencegahan telah dilakukan

Time to stop (date /time)

Waktu berhenti (tgl/jam)
Date Signature of responsible person / Supervisor (process)
This work will be allowed if the above meassure are carried out. I have understood about Safety meassure and obliged to follow
(Pekerjaan ini boleh dimulai bila semua pencegahan tersebut diatas sudah dilakukan) Saya mengerti tentang tindakan-tindakan keselamatan dan wajib diikuti.
Date / Tgl :
Date / Tgl Signature of Faculty's OSH Unit Signature of work group leader/attendant :
Tanda tangan perwakilan P2K3 FT Tanda tangan pimpinan kerja
Signature of responsible person from service dept :
Tanda tangan orang yang bertanggung jawab dari departemen
Green : Work Group Leader/ at site
Yellow : Ketua K3 Departemen