S.H.E.

CLEARANCE FORM
REQUIREMENTS TO GET WW ID BADGE

To work at WW area, must FIT & pass SHE induction. Utk bekerja di WW harus sehat dan lulus SHE induction.

Company Name POLBAN & TELKOM UNIV. Company phone no. Working Area SEGWWL (PS & SAGS)

Contractor supervisor Cont. spv phone no. Type of Work Praktek Kerja Lapangan
Contractor to fill & submit this form to WW medic 3 days prior induction, attachments copy of: health certificate (MCU), identification card & competency certificate. Kontraktor mengisi & mengirim form ini
ke WW medic 3 hari sebelum induksi, disertai copy lampiran: surat sehat (MCU), tanda pengenal, & sertifikat kompetensi.

Y N The contract will utilize operational vehicle. Kontrak ini akan memakai kendaraan operasional. (Vehicle shall inspect by WW SHE, driver must pass WW SIM).
Y N The contract will require additional local manpower. Kontrak ini akan membutuhkan tambahan pekerja lokal. (Coordinate with ER team)

Job Work Competency Induction

No Name Position Duration Certificate Signature* date* Induction result# MCU result#

1 M. Akbar Alghifari PKL 1,5 months 1 24-06-24 1 1 FIT

2 Aufa Rafiqi Mulyana PKL 2 months 2 24-06-24 2 2 FIT
3 3 3 3
4 4 4

Saya sudah menerima penjelasan Aturan Kerja di WW, saya mengerti dan akan mematuhi selama bekerja di Wayang Windu area.
Jika kedapatan saya melanggar aturan kerja WW, saya bersedia ditegur & menerima konsekuensi sesuai aturan yg berlaku.
Hereby, I have received explanation of WW Work Rules; I am understood and will abide by while working in the Wayang Windu area. If caught violating
the WW rules, I am willing to be remind and receive all the consequences according applicable rules.

Contractor Spv WW/SE Contract Spv Inducted by SHE Representative Remarks:

Teja Prasetya
Notes: * to fill during SHE induction; # to fill by WW SHE team; SHE induction material refer to ‘SPE.WR.101c General SHE Rules.doc’

WWMS Form: SPE.WR.101a Page 1 of 1 Print Date: 21 June 2024