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PT.

PUTRA TUNGGAL MANDIRITAMA

INDUCTION CHECKLIST
Name : Dept. : Company :
Date : Location :
Subject :
Work Permit No. :

No. Description Initial* Applicable Remarks


1 Access Card v, w
2 Muster point located v, w show the map
3 How is the Escape Route? v, w show the map
4 Lifeboat/life rafts/life jackets stations (if applicable) v, w used for sea/ water transportation only
5 Where's the Medic facilities? v, w show the map
6 Overview of the work permits system. w as per risk assessment
7 Location of workshops. w
8 Personnel Protective Equipment (PPE) w
9 Specific personnel protective equipment required (if any). w
Specific safety equipment available e.g. eyes wash, shower,
portable fire extinguishers etc.
10 Colour coding of lifting equipment. w
11 Waste disposal and general housekeeping rules. w
12 Changing / locker rooms (if applicable) w
13 Tea and meal breaks. w
14 Specific rules concerning work away from the process area e.g. w
wearing of life jackets, radio, etc.
15 HSE Booklet w

note * v : Visitor
w : Worker

Inductor, Inductee,

........................................................ .........................................................

SFT-012/ATC-001
HSE RECORD

HSE INDUCTION
PT. PUTRA TUNGGAL MANDIRITAMA HSE

SELAMAT DATANG DI PT. PUTRA TUNGGAL MANDIRITAMA


KESELAMATAN ANDA ADALAH TANGGUNG JAWAB KITA BERSAMA

WELCOME TO PT. PUTRA TUNGGAL MANDIRITAMA


YOUR SAFETY IS OUR RESPONSIBILITY
Tanggal
:
Date
Perusahaan
:
Company
Proyek
:
Project

PERSONAL DATA
Data Pribadi

Nama
:
Name
Jabatan
:
Position
Alamat
:
Address

EMERGENCY CONTACT NUMBER


Nomor Keadaan Darurat yang dapat dihubungi

Nama
:
Name
Alamat
:
Address
Telepon
:
Telephone

SAFETY INDUCTION
Induksi Keselamatan

No SUBYEK/ SUBJECT OK NO No SUBYEK/ SUBJECT OK NO


KEBIJAKAN K3LL PT. PTM SISTEM IJIN KERJA
1 6
HSE Policy of PT. PTM Work Permit System
TARGET DAN SASARAN K3LL SIRINE DAN NOMOR TELPON DARURAT
2 7
HSE Objective dan Target Emergency Alarm and Contact Number
ALAT PELINDUNG DIRI KESELAMATAN LINGKUNGAN
3 8
Personal Protective Equipment Environment
PROSEDUR KEADAAN DARURAT MENGIKUTI SEMUA PERATURAN KESELAMATAN
4 9
Emergency Response Procedure Follow All Safety Regulation
AKTIFITAS BISNIS DAN POTENSI BAHAYA LAIN - LAIN
5 10
Scope of Bussiness & Hazard Potenstial Others

Saya yang bertanda tangan dibawah ini telah mengikuti Program Pengenalan Keselamatan Kerja, dan mengerti
serta akan mengikuti peraturan yang berlaku di PT. Putra Tunggal Mandiritama

Which undersigned has followed and understand Safety Orientation and will obey PT. Putra Tunggal Mandiritama
Safety Rules

Masukan dan Saran / Input and Advice

Inductee Inductor Acknowledge,


EMPLOYEE/ VISITOR HSE DEPARTMENT SITE MANAGER
No : ATC/PTM/8AHSE-012-001

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