Pre-Qualification

New Contracts
Qualification Phase: Select A Qualified Contractor

Pre-Qualification CSMS
Risk Assessment Selection

Contract
Award Data Bank
Contract Implementation Phase: Ensure Field Safe Work

Pre-Job Activity Work In Progress Final Evaluation

 FORM VIII
PRE-QUALIFICATION HSE QUESTIONNAIRE
Company Name : PT. MITRA JASA ENGINEERING
Address : JL. RANTAU 29 GKB GRESIK
Phone : 031 - 3956290
Bid Number : BID-18-0031

SECTION 1 - LEADERSHIP AND TOP MANAGEMENT COMMITMENT

1 Commitment to HSE Through Leadership
a). How are senior managers is top management personally involved in HSE management activities, objective setting and monitoring?
Bagaimana para senior manager terlibat secara pribadi dalam manajemen K3LL, penetapan tujuan HSE dan monitoring?

The Managing Director accepts the overall responsibility of the policy. The managing director delegates his responsibility to the technical
director who delegates to Head of Departments and the Supervisors in ensuring that the policy, together with the Safety and Health
procedural requirements and instruction are read and understood by all employees as well as conductors and their associates

b). Provide evidence of commitment at all levels of the organization

Berikan bukti komitmen pada semua level organisasi

Please see our HSE Management Meeting

c). How do you promote a positive towards HSE matters?

Bagaimana anda mempromosikan nilai-nilai positif mengenai hal-hal yang menyangkut K3LL?

By distribution all HSE manual, HSE policies, HSE procedure and HSE issues, by training to all employees, demonstrated on the wall,
and communicate with HSE office in the field

Required Evidence:
Senior Management involvement in HSE matters
required evidence can be seen in (MSD-003-18) MJE Safety Document page 21 and additional attachment can be seen in attachment for
section 1

SECTION 2 - POLICY AND STRATEGIC OBJECTIVES

2.1 HSE Policy Documents
a). Does your company have an HSE policy document that is applied in this region? (yes / No) If yes, please attach.
Apakah perusahaan anda mempunyai dokumen Kebijakan K3LL di daerah/area ini? (ya/tidak) Jika ya, mohon dilampirkan

Yes, there are PT. Mitra Jasa Engineering HSE Policy, Drugs and Alcohol Policy, PPE Policy, and also Company Rule

b). Who has overall and final responsibility for HSE in your organization?
Siapa yang tanggung jawab tertinggi dan menyeluruh untuk K3LL di organisasi anda?

All personnel have a responsibility for HSE. However overall and final responsibility for HSE are managing Director and / or Technical
Director. And if the Managing director / Technical Director is not on office, they delegate to HSE Steering Committee Coordinator.

c). Who is the most senior person in the organization responsible for this policy being carried out at the premises and on site where his
employees are working? Please provide the name and title/position
Siapakah orang paling senior dalam organisasi yang bertanggung jawab terhadap kebijakan yang sedang dijalankan pada daerah
kewenangan dan lokasi dimana karyawannya bekerja?

Please see our attachment

d). Itemize the methods by which you have drawn your policy statement to the attention of all your employees.
Jelaskan secara rinci metoda-metoda yang anda gunakan untuk memastikan kebijakan K3LL menjadi perhatian karyawan-karyawan
anda?

a. By implementing inspection for site HSE implementation

b. Poster
c. Safety talk
d. Induction for new employee
e. HSE Board
 e). What are your arrangements for advising employees of changes in the policy?
Pengaturan apa yang anda punyai untuk memberitahu kepada karyawan mengenai perubahan-perubahan pada kebijakan K3LL?

The changes will be distributed by letter announcement and signed off by all employees. Please see our previous answer

Required Evidence:
- HSE policy
- Evidence of HSE Policy Socialization or Communication (distribution list, display on bulletin board, email or letter announcement, etc)
required evidence for HSE policy can be seen in (MSD-003-18) MJE Safety Document page 4 and page 40 for evidence of HSE Policy
Socialization
2.2 Periodic HSE Strategic Objective (Yearly)
Does your Company have HSE strategic objective? If YES, please provide the evidence.
Apakah Perusahaan Anda memiliki sasaran strategis K3LL? Jika YA, lampirkan buktinya.

Please see our attachment

Please explain in details the methods for ensuring the employees understand about HSE strategic objective in your Company?
Jelaskan secara rinci metode-metode yang Anda gunakan agar karyawan mengerti tentang sasaran strategis K3LL?

By documenting and socializing these strategic goals including to new employees

Required Evidence:
- HSE Objectives required evidence can be seen in MSD (MJE Safety Documen) page 4
- Evidence of HSE Objective Establishment (Minutes of Meeting, Attendance List, etc.). required evidence can be seen in MSD (MJE
Safety Documen) page 9 for form and for sample MOM attachment section 2

SECTION 3 - ORGANIZATION, RESPOSIBILITY, RESOURCES, STANDARDS AND DOCUMENTATION

3.1 Organization Structure to Manage HSE
a). How is your company structured to manage and communicate HSE effectively?
Bagaimana struktur organisasi perusahaan anda dibuat untuk mengelola dan mengkomunikasikan K3LL secara efektif?

By established HSE management system, distributed to all manager. Manager conduct safety manner to supervisor and crew. And
All manager give input related to HSE to HSE manager.

b). Does HSE Meetings promote the understanding of HSE?

Apakah pertemuan-pertemuan K3LL mempromosikan pemahaman K3LL?

Yes, it promotes the understanding of HSE.

c). Does your Company conduct reguler meeting with the Contractor to discuss and follow-up the interface condition?
Apakah klien dan kontraktor bertemu secara reguler untuk mendiskusikan dan menindaklanjuti situasi “Interface”?

Yes, we conduct reguler meeting with the Contractor to discuss and follow-up the interface condition

d). What provision does your company have for HSE communication meetings?
Ketentuan apa yang dibuat perusahaan anda untuk pelaksanaan pertemuan K3LL?

Please see attachment.

Required Evidence:
- HSE Organization Structure required evidence can be seen in MSD (MJE Safety Documen) page 32
- Job Descriptions of HSE Personnel required evidence can be seen in MSD (MJE Safety Documen) page 33
- Evidence of HSE Meeting program and schedule at all levels and implementation required evidence can be seen in MSD (MJE Safety
Documen) page 9 for form and for sample MOM in page attachment section 3

3.2 HSE Training of Manager/Supervisor

a). Have the managers and supervisors at all levels that will plan, monitor, oversee and carry out the work received formal HSE training
in their responsibilities with respect to conducting work to HSE requirements? (Yes / No) Please provide the evidence
Sudahkah para manajer dan supervisor di semua jenjang yang akan merencanakan, memonitor, mengawasi dan melaksanakan
pekerjaan menerima pelatihan K3LL yang resmi dalam tanggung jawab mereka dengan tujuan untuk menjalankan pekerjaanya sesuai
dengan persyaratan K3LL? (Ya/Tidak) Mohon dilampirkan buktinya.

Yes, Training is given to Managers, Supervisor (Field team leader) by external training and in-house training. Example: PPE training
(in-house training), scaffolding training (external training). Please see attachment.
 b). If the training is given in-house, please describe the content and duration of courses.
Jika pelatihan diberikan in-house, jelaskan isi dan lamanya pelatihan.

The training is about PPE training with two days duration.

c). How have you identified areas of your company’s operations where specialized training is required to deal with potential hazards (for
example: radioactive, asbestos and chemical)?
Bagaimana anda telah mengidentifikasi lokasi di dalam orperasi anda dimana pelatihan khusus diperlukan untuk menghadapi potensi
bahaya (misalnya : radioaktif, asbes dan bahan kimia)?

Directors and senior managers have >10 years experience operations. And they have identified potential hazards that are generally
common. However PT. Mitra Jasa Engineering prepared Emergency Response Procedure to ensure all employees are aware of
onsite work risk and guide all employees on do the safety jobs. Specialised training to deal with potential hazards includes:
- First Aid training
- PPE Training
- Fire drill training
- Emergency Response Training
d). What type of HSE Specialist that employed by your Company?
Sumberdaya spesialis K3LL apa saja yang dimiliki oleh Perusahaan Anda?

General HSE expert.

e). How does your Company provide specialized HSE Training for HSE Personnel?
Bagaimana Perusahaan Anda menyediakan pelatihan kekhususan kepada staf K3LL?

We provide specialized training to hse staff who require certification in the field of work to be undertaken.
Required Evidence:
- HSE training program for staff required evidence can be seen in MSD (MJE Safety Documen) page 76
- HSE Training matrix for staff (training matrix is training requirement for each position) required evidence can be seen in MSD (MJE Safety
Documen) page attachment section 3.2
- HSE training record for all staff related to the work required evidence can be seen in MSD (MJE Safety Documen) page attachment 3.2
- HSE Training materials required evidence can be seen in MSD (MJE Safety Documen) page 67

3.3 General HSE Training

a). What arrangements does your company have to ensure new employees have knowledge of basic industrial HSE, and to keep this
knowledge up to date?
Tindakan apa yang dilakukan perusahaan untuk memastikan semua karyawan baru mempunyai pengetahuan dasar K3LL dan
menjaga bahwa pengetahaun tersebut yang terbaru (up todate)?

Giving HSE training to all employees regularly. Their knowledge is up-dated on a regular basis by regular meetings, seminars and
training. In addition, a start of fieldwork all field teams are given a safety briefing / safety induction meeting on site
b). What arrangements does your company have to ensure all employees, including sub contractors, also have knowledge of your HSE
policies and practices?
Tindakan apa yang dilakukan perusahaan untuk memastikan bahwa semua karyawan, termasuk subkontraktor, juga mempunyai
pengetahuan tentang Kebijakan K3LL, tata cara atau persyaratan K3LL Anda?

All new employees and subcontractor employees are given HSE induction meeting/ HSE training before they start to the fieldwork.
Their knowledge is up-dated on a regular basis by regular meetings / safety induction meeting on site. And all employees and
subcontractor’s employees have a copy all HSE policies and signed off when they read the policies.
c). What arrangements does your company have to ensure new employees and new subcontractor employee have been instructed and
have received information on any specific hazards arising out of the nature of the activities?
Pengaturan apa yang telah dibuat perusahaan anda untuk memastikan bahwa karyawan dan karyawan subkontraktor yang baru
telah diberi instruksi dan menerima informasi mengenai bahaya spesifik yang timbul dari sifat pekerjaan?

We give Safety Induction for new employees and subcontractor. We conduct daily toolbox meeting and work permit for special job.

Required Evidence:
- HSE training program for existing and new employee
- Orientation materials (booklet, hand out, etc),
- HSE Handbook (outlines, explains and demonstrates new employee's job)
- Evidence follow up observation of new employees work
depends on all required evidences above, it has been added to attachment MSD (MJE Safety Document) BAB 5 page 66

3.4 HSE Competency

a). Does your Company have a system for Competency? If YES, please explain the scope and content of the competency.
Apakah Perusahaan Anda memiliki sistem komptensi? Jika YA, jelaskan lingkup dan konten dari sistem kompetensi tersebut.

Yes, please see attachment.

 b). What arrangements does your company have to ensure the existing employees have knowledge of HSE, and to keep this knowledge
up to date? If training is provided in-house please give details of content.

Pengaturan apa yang telah dibuat perusahaan anda untuk memastikan bahwa karyawan yang sekarang mempunyai pengetahuan
tentang K3LL, dan untuk menjaga agar pengetahuan tersebut selalu up to date? Jika pelatihan diberikan secara in-house, berikan
rincian isi pelatihan.

We give the existing staff Re-Induction training.

Required Evidence:
- Procedure of HSE Competency
- Database of HSE Competency
- HSE Training Material related to HSE Competency improvement
- Evidence of HSE Competency Database monitoring
depends on all required evidences above, it has been added to attachment MSD (MJE Safety Document) BAB 3 page 33
3.5 Assessment of Subcontractors
a). Do you have subcontractor (s) selection procedure in term of HSE? (Yes / No) Please attached
Apakah anda mempunyai prosedur pemilihan subkontraktor (ya/tidak) Mohon dilampirkan

Yes, please see attachment.

b). How do you assess your subcontractor (s) to ensure they comply with your company's HSE standards (HSE Competency or HSE
Performance)? Please please provide the evidence
Bagaimana anda melakukan penilaian subkontraktor untuk memastikan sesuai dengan standar K3LL (kompetensi K3LL atau kinerja
K3LL) Perusahaan Anda? Mohon berikan buktinya

Please see our subcontractor procedure.

c). Where do you describe the HSE requirements that shall be complied by your Subcontractor?
Dimana Anda menejelaskan standar-standar yang anda tuntut agar dipenuhi oleh Subkontraktor Anda?

We spell out in the Work Order.

d). How do you ensure that the HSE requirements have been met and verified?
Bagaimana anda memastikan standar-standar K3LL telah dipenuhi dan diperiksa?

We ensure from HSE questionnaire and evidence attachment. If we think inadequate, we will interview the HSE Manager and
several subcontractor’s worker.

Required Evidence:
- Procedure for Subcontractor Selection
- Assessment program and standard for subcontractor
- Records/reports of assessment (e.g. pre-qualification) and performance monitoring (e.g. Work in Progress audit) results

3.6 HSE Requirements and Standards

a). How do you identify new industry or regulatory HSE standards that may be applicable to your activities?
Bagaimana perusahaan anda mengidentifikasi standar-standar industri baru atau peraturan-peraturan baru K3LL yang mungkin
berlaku bagi aktivitas anda?

We updating our regulatory compliance list every six month. Propose to management to comply to our workplace.

b). is there a system structure to create, update and disseminate the HSE standards?
Adakah struktur menyeluruh untuk membuat, memperbaharui dan menyebarkan standar K3LL?

We have procedure for controlling the revision of document and the changes made for all PT. Mitra Jasa Engineering, it is change
control procedure that implemented change request form. Please see attachment.
c). Do you have HSE standard? Does your standard aligned with OGP/industry best practices? Please explain
Apakah anda memilii standar K3LL? Apakah standar Perusahaan Anda sesuai dengan OGP/pedoman industri atau praktek-praktek
yang direkomendasikan? jelaskan?

Please see attachment.

Required Evidence:
- Procedure for indentification of HSE regulations and its compliances
- List of HSE regulations and standards and its references (e.g. local, global industry regulatory standard)
- Evidence of HSE Regulation Database monitoring

SECTION 4 – HSE RISK MANAGEMENT

4.1 Risk Assessment and Control
 How your Company identifies the hazards, assess and control, and mitigates the impacts, to a practically acceptable level (ALARP - as
low as reasonably practicable)?
Bagaimana Perusahaan Anda mengidentifikasi bahaya, menilai risiko, mengendalikan dan memitigasi dampak, ke tingkat yang dapat
diterima secara praktis (ALARP – as low as reasonably practicable)?

We use Risk Assessment Register. Please see our attachment.

Required Evidence:
- HSE Risk Management procedure/guideline
- Sample of HSE Risk Management implementation (e.g. record of risk assessments: JSA, HAZID, HAZOP, QRA, etc)
- Risk Register and Action Plan

4.2 Occupational Health Hazards

a). Do you have specific policies and programs about specific health hazards such as drug abuse, blood borne pathogens, malaria,etc?
Apakah Anda memiliki kebijakan khusus dan program mengenai bahaya-bahaya kesehatan yang spesifik seperti penyalahgunaan
obat-obatan, penyakit menular melalui darah (blood borne pathogens), malaria, dan lain-lain?

We conduct environment inspection annually.

b). What health hazards (chemical, vibration, noise, radiation, etc.) related to the scope of your activities? Explain how occupational
health hazards are identified, assessed and controlled?
Bahaya-bahaya kesehatan apa saja (kimia, getaran, kebisingan, radiasi, dll) yang berkaitan dengan ruang lingkup pekerjaan Anda?
Jelaskan bagaimana bahaya-bahaya kesehatan kerja diidentifikasi, dinilai dan dikendalikan.

There are chemical hazards, vibration hazards, noise hazards, radiation hazards, temperature hazards and ergonomic hazards. We
give our employees knowledge through safety talk, PPE. We conduct Medical Check Up to workforce. Provide MSDS when handling.
And only authorized certified personnel who could do these jobs.

c). What a system in your Company to control these hazards and monitor the effectiveness of their controls? Is regular employee exposure
monitoring a part of the system?
Sistema apa yang dimiliki Perusahaan Anda untuk mengendalikan bahaya-bahaya tersebut dan memantau efektifitas
pengendaliannya? Apakah pemantauan pajanan pekerja dilakukan secara regular merupakan bagian dari sistem tersebut?

We conduct safety hazards communication mechanism to the workforce.

Required Evidence:
- Health Policy
- Heath Risk Assessment
- Procedure / Program related to Health (HCP, Industrial Hygiene, Fit for Task, drug & alcohol test, health surveillance, etc.) and evidence of
implementation.
- Safety Hazards Communication mechanism (e.g. email, orientation, notice board, safety sign, etc) to the workforce of the major hazards that
they are likely to be exposed.
- Result/report of hazards exposure monitoring (Chemical, physical and biological hazards such as noise, radiation, vapors, fumes, temperature
extremes etc.)

4.3 Safety Hazards

a). What safety hazards (mechanical guarding, working at height, lifting and rigging, confined space entry, explosive atmosphere, etc.)
related to the scope of your activities?
Bahaya-bahaya keselamatan apa saja (mechanical guarding, bekerja di ketinggian, pengangkatan dan tekel, masuk ruang terbatas,
atmosfir eksplosif, dll) yang berkaitan dengan ruang lingkup pekerjaan Anda?

lifting and rigging, working at height, permit to work, energy isolation, etc.
b). What a system in your Company to controls these hazardsdan monitor the effectiveness of their controls?
Sistem apa saja yang tersedia untuk mengendalikan bahaya-bahaya tersebut dan memantau efektifitas pengendaliannya?

We conduct safety hazards communication mechanism to the workforce

Required Evidence:
- HSE Risk Assessment
- Procedure / Program related to Safety (lifting and rigging, working at height, confined space entry, energy isolation, permit to work,
transportation, etc.)
- Evidence of Procedure / Program implementation.
- Hazards Communication mechanism (e.g. email, orientation, notice board, safety sign, etc) to the workforce of the major hazards that they
are likely to be exposed.
4.4 Logistics Hazards
 a). What type of logistics hazards (land, air, sea transportations, handling of material, etc.) related to the scope of your activities?
Bahaya-bahaya kegiatan logistics apa saja (transportasi darat, udara, laut, penanganan bahan/material, dll) yang berkaitan dengan
ruang lingkup pekerjaan Anda?

There are hazards in scaffolding work field. The hazards are related with working at height such as slip, fall, and pinched during
installation of scaffolding.

b). What a system in your Company to controls these hazardsdan monitor the effectiveness of their controls?
Sistem apa saja yang tersedia untuk mengendalikan bahaya-bahaya tersebut dan memantau efektifitas pengendaliannya?

We have procedure for working at height, safety scaffolding procedure, and give the workforce the basic knowledge about scaffolding.

Required Evidence:
- HSE Risk Assessment related to losgistic activities
- Procedure / Program related to logistic activities (lifting & rigging, transportation, vehicle inspection, handling of hazardous substance, etc.)
- Evidence of Procedure / Program implementation.

4.5 Environmental Hazards

a). What type of environmental hazards (chemical spill, air emissions, waste disposal, etc.) related to the scope of your activities?
Bahaya-bahaya lingkungan apa saja (ceceran/tumpahan bahan kimia, emisi udara, pembuangan limbah, dll) yang berkaitan dengan
ruang lingkup pekerjaan Anda?

Environmental hazards associated with the installation of scaffolding in the work area include gas leakage or exposure to chemicals.
b). What a system in your Company to controls these hazardsdan monitor the effectiveness of their controls?
Sistem apa saja yang tersedia untuk mengendalikan bahaya-bahaya tersebut dan memantau efektifitas pengendaliannya?

By using standard operational procedures and using leakage gas detector tool.

Required Evidence:
- Environmental Aspects and Impact Register
- Procedure / Program related to environmental activities (waste disposal, oil spill handling, environmental audit, etc.)
- Evidence of Procedure / Program implementation.

4.6 Security Hazards

a). What type of security hazards (terrorism, kindanpping, robbery, etc.) related to the scope of your activities?
Bahaya-bahaya keamanan apa saja (terorisme, penculikan, perampokan, dll) yang berkaitan dengan ruang lingkup pekerjaan Anda?

Security hazards associated with theft of work tools such as scaffolding in the workplace.

b). What a system in your Company to controls these hazardsdan monitor the effectiveness of their controls?
Sistem apa saja yang tersedia untuk mengendalikan bahaya-bahaya tersebut dan memantau efektifitas pengendaliannya?

By ensuring that all storage places of goods and equipment are securely locked before leaving the workplace

Required Evidence:
- Risk Assessment related to security activities
- Procedure / Program related to security activities (terrorism, kindanpping, robbery, etc.)
- Evidence of Procedure / Program implementation.

4.7 Social Aspect Hazards

a). What type of social aspects hazards related to the scope of your activities?
Bahaya-bahaya sosial apa saja yang berkaitan dengan ruang lingkup pekerjaan Anda?

Social hazards that include job stress and excessive workload.

b). What a system in your Company to controls these hazardsdan monitor the effectiveness of their controls?
Sistem apa saja yang tersedia untuk mengendalikan bahaya-bahaya tersebut dan memantau efektifitas pengendaliannya?

By taking an individual approach and an organizational approach so that workers are able to manage job stress.

Required Evidence:
- Risk Assessment related to Social Aspect activities
- Procedure / Program related to Social Aspect
- Evidence of Procedure / Program implementation.
4.8 Personal Protective Equipment
a). What arrangements does your company have for provision and keep of personal protective equipment and clothing, both standards
issue, and that required for specilized activities? Please attach
Pengaturan apa yang dimiliki perusahaan untuk penyediaan dan menjaga PPE dan baju kerja, standard dan persyaratan yang diminta
untuk pekerjaan tertentu? Mohon dilampirkan

We have a procedure of Personal Protective Equipment (PPE). All employees must be use Personal protective equipment shall be
provided and worn where:
- Hazards cannot be otherwise prevented or suitably controlled, e.g. by engineering or administration controls, total enclosure,
substitution.
- Complete protection is essential, e.g. in some occupational environments with uncertain levels of hazards, or
- Legislation required it.
The provision and use of personal protective equipment does not reduce or replace the need for proper accident prevention measures,
such as engineering or administrative controls, to be undertaken. Specification of such preventive measures must always be fully
explored before consideration of issue of personal protective equipment.

b). Do you provide appropriate personal protective equipment (PPE) for your employees? (Yes / No) Please provide a listing of the PPE
for the scope of this work.
Apakah anda menyediakan PPE yang sesuai untuk karyawan anda? (ya / tidak) Mohon dibuatkan list PPE untuk scope kerja ini.

Yes, the PPE we provide are safety helmet, full body harness, hand gloves, coverall, safety shoes, and safety glasses.

c). Do you provide training on how to use PPE? (Yes/ No) Explain the contents of the training and any follow up.
Apakah anda menyediakan training bagaimana memakai PPE? (ya/tidak) Jelaskan isi pelatihan tersebut dan tindak lanjutnya.

Yes, through safety talk. Follow up by conduct PPE inspection.

d). Do you have a program to ensure that PPE is impacted and maintained?
Apakah anda mempunyai program untuk memastikan PPE digunakan dan dirawat.

We conduct impacted PPE Inspection, we ensure the stockiest. We ensure every workforce maintain the
PPE. Every safety talks we remind every worker to use PPE. We communicate to find best PPE to wear at the workplace.

Required Evidence:
- PPE procedure
- List of PPE as company standard with the specifications
- PPE inspection records
- PPE inventory and stock
- PPE training material and records
- Evidence of PPE distributions

SECTION 5 - PLANNING AND PROCEDURES

5.1 HSE Operations Manuals
a). Do you have HSE manuals? (yes / No) If Yes, Please attach the list of content
Apakah anda mempunyai Manual K3LL? (ya/tidak) Jika ya, mohon dilampirkan list (isinya)

Yes, please see attachment.

b). How do you ensure that the working practices and procedures used by your employees on-site are consistently in accordance with
your HSE policy objectives and arrangements?
Bagaimana anda memastikan bahwa working (standard) praktis dan working (standard) prosedur digunakan oleh karyawana andan
dilapangan secara konsisten sesuai dengan tujuan Kebijakan K3LL dan pengaturan K3LL?

Our HSE officer will ensure that the working practices and procedures used by our employees on site are consistently in accordance
with our HSE policy objectives and arrangements. Project manager responsible to ensure safety working practices and procedures
used by all employees including subcontractor on site.
Required Evidence:
- HSE Manual
- HSE Procedure
- HSE Document control procedure (e.g. system for updating and dissemination to employees)

5.2 Equipment Control and Maintenance

 How do you ensure that plant and equipment used within your premises, on-site, or at other locations by your employees are correctly
registered, certified with regulatary requirement, inspected, controlled and maintained in a safe working condition? Please provide the
evidence
Bagaimana anda memastikan bahwa plant/pabrik dan peralatan yang digunakan di ruang lingkup usaha anda, di lapangan dan lokasi
lain oleh karyawan anda tercatat dengan benar, bersertifikat secara regulelr, diinspeksi, dikotrol dan dirawat dalam kondisi kerja yang
aman? Mohon berikan buktinya

We act in accordance with government regulation or industrial standard to ensure that plant and equipment used within our promises,
on site or at other location by our employees are correctly registered, certified with regulatory requirement, inspected, controlled and
maintained in a safe working condition.

Required Evidence:
- Procedure for Certification, Callibration and Maintenance of equipment
- Equipment inspection/certification and maintenance program / schedule / plan
- Evidence of third party inspection/certification
- Evidence of equipment inspection records and follow up
- Evidence of equipment inspection finding follow up

5.3 Management of Change

How do you manage the change and assess risks related to personnel, equipment, processes and documentation?
Bagaimana anda mengelola perubahan dan menilai risiko terkait personil, peralatan, proses dan dokumentasi?

We manage changes and assess risks related to personnel, equipment, processes and documentation using the management of
change procedure. Please see attachment.

Required Evidence:
- Management of Change Procedure
- Evidence of Management of Change implementation
- Evidence of Management of Change records and follow up
- Management of Change Register

5.4 Emergency Response Plan

a). Do you have an Emergency Response Plan? (Yes / No) If Yes, please attach
Apakah anda mempunyai Emergency Response Plan / procedure? (ya/tidak) Jika ya, mohon dilampirkan

Yes, please see attachment.

b). What emergency situations are covered?

Situasi darurat apa yang tercakup?

• Accidents
• Fire
• Earthquake
• Explosion
• Bomb threats

Required Evidence:
- Emergency Response Plan Procedure
- Emergency Organization Structure
- Emergency Drill Schedule
- Evidence of Emergency Drill Program (Scenario, Report and follow-up)
- List of Training for Emergency Response Teeam

SECTION 6 - IMPLEMENTATION AND PERFORMANCE MONITORING

6.1 HSE Management System Implementation and Performance Monitoring
a). What arrangement(s) does your company have for supervision and monitoring of HSE performance?
Pengaturan apa yang perusahaan anda miliki untuk men-supervisi dan monitoring performance K3LL?

Measurements of HSE performance using proactive measurement methods and reactive measurement methods in the workplace
using the necessary equipment. Prioritizing the measurement of HSE performance using proactive measurement methods in order
to encourage the improvement of HSE performance and reduce the incidence of workplace accidents.
b). How your Company ensures the implementation of work procedures at site? for example: compliance with procedures, toolbox
talks, HSE meetings, supervision, job observation.
Bagaimana Perusahaan anda memastikan implementasi dari prosedur-prosedur kerja di lokasi kerja? misalnya : kepatuhan
terhadap prosedur, toolbox talks, pertemuan K3LL, pengawasan, observasi pekerjaan.

We ensure the implementation of work procedure by conducting routine safety patrol and safety inspection.
 c). How do you monitor employee performance related to HSE? For example: hazard identification process, participation in HSE, etc.
Bagaimana Anda memantau kinerja K3LL karyawan? Misalnya : sistem identifikasi bahaya, partisipasi K3LL, dll

The Company delegated the task of monitoring and measuring the performance of OSH to the company's General HSE expert.
Furthermore, the results of monitoring and measurement of K3 performance will be analyzed and used to identify how much
success K3 performance applied.
d). What arrangements does your company have for monitoring the HSE Performance (e.g. when there is no incident)?
Pemantauan K3LL aktif apa saja yang dilakukan (misalnya saat tidak terjadi insiden)?
Assessment of conformity with legislation and other regulations relating to HSE implementation in the workplace, effectiveness of
inspection results and monitoring of hazard conditions in the workplace, effectiveness of worker's participation on HSE implementation
in the workplace, survey of labor satisfaction level on HSE implementation in place work, assessment of the effectiveness of HSE
training, and assessment of work activities related to corporate health and safety risk.
e). What arrangements does your company have for reporting and follow-up the findings?
Bagaimana Anda melaporkan dan memperbaiki kelemahan-kelemahan yang teridentifikasi?
By conducting HSE performance evaluations, decide on actions to address any weaknesses and systems to monitor their
implementation, and consider live reviews with a focus on major weaknesses or events.

f). What arrangements does your company have to communicate the HSE Performance Results to related personnel?
Bagaimana Anda mengkomunikasikan hasil-hasil dari pemantauan kinerja aktif kepada personil yang relevan?
Management disseminates and implements hazard identification and evaluation procedures and internal audit procedures to all
employees. company's rules to deliver any results and findings from its supervision and monitoring to management are through
company announcement letter.

Required Evidence:
- HSE Performance Procedure
- HSE Performance Report (Lagging and Leading Indicators)
- Evidence of HSE Performance Report dissemination / communication to Management and Employees
- HSE incident statistics and analysis
- Evidence of HSE performance recognition from clients

6.2 HSE Performance Indicators

Please provide records of your incidents statistics for each year in the last five years:
Berikan catatan mengenai insiden statistik tiap tahun untuk 5 tahun terakhir:

 Number of Fatalities Jumlah Kasus Kematian

 Lost Time Injuries Jumlah Kecelakaan Kehilangan Hari Kerja
 Lost Workday Cases Jumlah Hari yang Hilang Karena Kecelakaan
 Restricted Work Day Cases Jumlah Kasus Kecelakaan Restricted Work Day
 Medical Treatment Cases Jumlah Kasus Penanganan Medis
 First Aid Cases Jumlah Kasus P3K
 Near Miss Cases Jumlah Kejadian Nyaris Celaka
 Fatal Accident Rate Rasio Jumlah Kasus Kematian
 Lost Time Injury Frequency Rate Rasio Jumlah Kecelakaan Kehilangan Hari Kerja
 Total Recordable Incident Rate Rasio Jumlah Kasus Kecelakaan Kategori Recodable
 Other Specific HSE Performance Indicator (if any) Indikator Kinerja K3LL lain yang Spesifik (jika ada)
Please provide definitions of the above HSE Performance Indicators in your Company.
Berikan defini Perusahaan anda mengenai istilah-istilah Indikator K3LL di atas.

Required Evidence:
- Incident Statistics in the last 5 (five) Years with reference to national and or international standard (e.g. Depnaker, OSHA, ANSI, etc)
- Definition of HSE Performance Indicators in your Company

6.3 HSE Performance Records

a). How is health performance monitored and recorded?
Bagaimana kinerja kesehatan dipantau dan dicatat?

Human Resources Department recorded any data of health performance from employee’s base on Hospital evaluation and test.
b). How is environmental performance monitored and recorded?
Bagaimana kinerja lingkungan dipantau dan dicatat?

HSE Department recorded any report of environmental performance on monthly basis.

 c). How is safety performance monitored and reported?
Bagaimana kinerja keselamatan dipantau dan dicatat?

Safety performance monitored and reported by HSE safety measurement methods proactively and reactively in the workplace.
d). How and what type of nearmiss case reported?
Bagaimana dan insiden nearmiss apa saja yang dilaporkan?

Every worker feel free to tell all the near miss in safety talk so others could learn spontaneously at that moment or direct to
supervisor.
e). How often is HSE Performance reviewed? By whom?
Seberapa sering kinerja K3LL ditinjau? Oleh siapa?

Monthly, by HSE Manager and it is discussed with all manager on former weekly meeting every month.
f). How is security performance monitored and reported?
Bagaimana kinerja keamanan dipantau dan dicatat?

Security performance monitored and reported through coordination with the employer by providing data equipment and data
workers who are doing the work.
g). Did our record the vehicle incident?
Apakah anda mencatat insiden kendaraan?

Yes, we did.

Required Evidence:
- Health Performance Record
- Safety Performance Record
- Environmental Performance Record
- Security Performance Record
- Vehicle Incident Record
- HSE Performance Analysis
- Evidence of HSE Performance reviewed by Top Management
6.4 Incident Investigation and Reporting
a). What kind of HSE incident are investigated?
Insiden K3LL apa saja yang diinvestigasi?

All occupational accidents known or reported resulting in loss of property ranging from small to large, human casualties ranging
from minor injuries to fatality, human casualties from occupational diseases, and property loss or injury / disease to human victims.
b). What process / method is used to investigate the HSE incident?
Proses / metode apa yang digunakan untuk menginvestigasi insiden K3LL?

Taking action as soon as possible, collecting evidence, inserting in order of evidence, analyzing information, performing corrective
action, follow-up on corrective action, and documentation of Investigation of a report.
c). Who conducts the investigation of HSE incident?
Siapa yang melakukan investigasi insiden K3LL?

Supervisor, safety manager, safety officer.

d). How are the findings of incident investigation results followed-up to ensure the effective prevention and avoid re-occurance?
Bagaimana temuan-temuan hasil investigasi insiden di tindaklanjuti untuk memastikan pencegahan yang efektif agar insiden yang
serupa tidak terulang kembali?

By documenting the investigation of the report, i.e writing a report to explain what happened, why it happened and what can be done
to prevent similar incidents.

e). How does the lesson learned from an incident be communicated to all relevant personnel?
Bagaimana pelajaran yang diperoleh dari suatu insiden dikomunikasikan kepada semua personil yang relevan?

We communicate in HSE Management meeting for management, Investigation meeting with supervisor and project manager. The
investigation result was communicated to employees through safety talk and poster.
Required Evidence:
- Incident investigation and reporting procedure
- Sample of incident report and investigation result (including investigation for near miss case)
- Evidence of incident investigation result/finding sharing (e.g. root causes and lesson sharing using email, notice boards, etc)
- Evidence of HSE performance improvement initiatives based on incident learning
- List of incidents and follow-up status
- Incident actions tracking system / register
6.5 Statutory Notifiable Incidents/Dangerous Occurrences, Improvement Requirement and Prohibition Notices
 Does your company sufferers any improvement requirement or prohibition notices on statutory notifiable incidents/dangerous occurances
by the relevant national body, regulatory body for HSE or other enforcing authority or been prosecuted under any HSE legislation in the
last five years? (Yes / No)

If Yes, please give the number of occurences and its short description.

Apakah perusahaan anda pernah mendapatkan permintaan perbaikan atau pemberitahuan larangan berkaitan dengan insiden atau
kejadian yang berbahaya dari badan nasional yang relevan, badan pengatur K3LL atau otoritas yang berwenang dalam peraturan K3LL
dalam 5 tahun terakhir? (ya/tidak)

Jika ya, berikan jumlah kejadiannya dan dskripsi singkat.

Our company that has not experienced any disruption or openness in the event of a hazardous event / event by a relevant national body,
regulatory body for HSE or other law enforcement key or estimated under the HSE legislation for the past five years.

Required Evidence:
- Letter received from regulatory body regarding major incident in the last five years
- Record of incident case occurred in your company

SECTION 7 – HSE AUDIT AND MANAGEMENT REVIEW

7.1 HSE Audit
a). Do you have a written policy/procedure on HSE auditing? (Yes / No) If yes, please attach
Apakah anda mempunyai kebijakan / prosedur tertulis untuk audit HSE? (ya/tidak) Jika ya, mohon dilampirkan

Yes, described in procedure, please see our audit record and also HSE Time Table Program/Plan.
b). Who is involved in the HSE Audit? How the Audit Team selected to ensure their competencies and independend from the area to be
audited? Is there any qualification to be assigned as Auditor?
Siapa yang terlibat dalam melakukan Audit HSE? Bagaimana anggota tim Audit dipilih agar memiliki keahlian khusus dan independen
dari aktivitas-aktivitas yang di audit.

Audit team that involved in hse audit is already certified HSE auditor.
c). How does your Company define the HSE Audit Schedule and HSE Audit scope / coverage?
Bagimana kebijakan/prosedur tersebut menetapkan standard audit, jadwal, ruang lingkup dan kualifikasi para auditor?

The standars is OHSAS 18001:2007 clause 4.5.5 (Occupational Health and Safety Management System Requirement) Audit would
be done to see whether the policy has been implemented, maintained in every organization activities, minor to major. Audit result
would be checked again for validation. Auditor : Our self (Manager, Supervisor from every department) for internal auditing, and
WQA for external Auditing.
d). How is the effectiveness of auditing verified and how does management report and follow up audits?
Bagimana efektifitas audit diverifikaksi dan bagaimana report ke manajemen dan tindak lanjut audits?

We follow up the audit as soon as possible. Please see management Minutes of Meeting and also evidence of follow.

Required Evidence:
- HSE Audit procedure
- HSE Audit program and implementation (schedule, scope/coverage, etc.)
- HSE Auditor comptency
- Management Involvement in the HSE Audit
- Evidence of HSE Audit report and follow up
- HSE Audit Finding Register / Tracking of findings

7.2 HSE Management Review and Follow-up

a). Do you have a written policy/procedure of HSE Management Review? (Yes / No) If yes, please attach
Apakah anda mempunyai kebijakan / prosedur tertulis mengenai tinjauan manajemen K3LL? (ya/tidak) Jika ya, mohon dilampirkan

Yes, please see attachment.

b). How often HSE Management Review conducted in your Company and who is involved in the process?
Seberapa sering tinjauan sistem manajemen K3LL dilakukan dan siapa saja yang terlibat dalam proses tersebut?

For internal review conducted every month and HSE management review done by the employer when the company update its
safety system.
c). How is the effectiveness of HSE Management Review recommendation verified and how does management report and follow up?
Bagaimana rencana pengendalian diidentifikasi dan upaya-upaya perbaikan dicatat dan ditelusuri agar tindak lanjut berjalan efektif?

The results of the audit are given to the responsible party in the audit area. audit and follow up actions are the responsibility of the
HSE coordinator. The results of audit reports are reviewed by management in all parts of the HSE management system.
Required Evidence:
- HSE Management Review Procedure
- HSE Management Review Minutes of Meeting
- HSE Management Review Report and follow up

SECTION 8 - HSE MANAGEMENT - OTHER ACHIEVEMENT

8.1 HSE Management System Certifications

Provide information about HSE Management System Ceritication that you have received from Certification Body.
Berikan informasi mengenai sertifikasi yang pernah anda terima dari badan sertifikasi.

Sea survival certification, scaffolder certification by SKT Migas, inspector scaffolder by SKT Migas, General HSE Expert certification,
Certification ISO 9001:2008, Certification OHSAS 18001:2007, Certification SMK3.

Required Evidence:
- List of Procedures in accordance with International Standards.
- Evidence of Compliances towards International Standards.
- Copy of HSE Management Certification from Certification Body

8.2 Member of Association

Describe the extent of your Company's participation in organizations relevant industry, commerce and government.
Jelaskan sejauh mana partisipasi perusahaan Anda pada organisasi-organisasi industri yang relevan, perdagangan dan pemerintahan.

We always update the data needed by SKT Migas and we always conduct training both safety training and technical training if the
expiration period has expired and we attend the event organized by KKKS.

Required Evidence:
- List of association membership
- Certificate of association membership (e.g. KADIN, APINDO, IAKKI, AK3, BSC)
- Evidence of active participation in HSE association (e.g. attending association event, etc)

8.3 HSE Management - Additional Features

Does your Organization (Global, Regional or Local) have specific or additional features that not described in this questionnaire?
Apakah Organisasi Anda (Global, Regional atau lokal) mempunyai ciri atau kekhususan lain yang belum dijelaskan pada kuesioner ini?

If Yes, please explained

Jika ya, mohon jelaskan

Yes, our company have uniqueness to cultivate teamwork by an internal race in the field of safety.

Required Evidence:
- Evidence of additional features of your Company