Safety, Health and Environment Management Systems

SUB-CONTRACTOR’S SAFETY, HEALTH AND ENVIRONMENT Rev : 1

PRE-QUALIFICATION / ASSESSMENT QUESTIONNAIRE
Date : 3 Jan 2018

SUBCONTRACTOR
HSE MANAGEMENT SYSTEM

Company Name

Phone Number

Address

Contact Person

Date

Section 1: HSE Policy & Leadership

Section 1: Kebijakan HSE dan Kepemimpinan
1. Does your company have an HSE policy document?
Apakah perusahaan anda mempunyai Kebijakan Keselamatan Kerja, Kesehatan dan
Lingkungan?

Please Attach: HSE Policy Signed, Update Policy

Answer:

2. Itemize the methods by which you have drawn your policy statement to the attention of all
your employees ?
Sebutkan metode-metode yang anda pergunakan untuk menarik perhatian semua
karyawan anda terhadap pernyataan tertulis mengenai kebijakan perusahaan anda?

Please Attach: HSE Policy Socialization

Answer:

Section 2: General Organisation - Management Structure / Organisation

Section 2: Organisasi Umum – Struktur Manajemen/Organisasi
1. How are senior managers personally involved in HSE management?
Bagaimanakah secara pribadi manajer-manajer senior terlibat dalam pengelolaan HSE?
(harap dijelaskan)

Please Attach: Site Visit Activity, MOM

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 Safety, Health and Environment Management Systems

SUB-CONTRACTOR’S SAFETY, HEALTH AND ENVIRONMENT Rev : 1

PRE-QUALIFICATION / ASSESSMENT QUESTIONNAIRE
Date : 3 Jan 2018

Answer:

2. Please attach a current organisation chart showing reporting relationships from your Director
to lowest line manager
Silahkan lampirkan struktur organisasi perusahaan anda mulai dari Direktur Utama sampai
ke Manager

Please Attach: Organization Charts with personnel highlighted

Answer:

3. Does a full time HSE Department exist in your organisation? Please also attach job
descriptions & Qualifications
Apakah Departemen HSE tersedia di perusahaan anda? Dilampirkan juga Job Des &
Qualifikasi masing-masing posisi

Please Attach: Organization charts which explain HSE functions, responsibilities & Qualifications

Answer:

Section 3: HSE Planning & Procedure

Section 3: Rencana & Prosedur HSE
1. Do you produce an HSE Plan for each Project? Please attach HSE Plan
Apakah anda menyiapkan HSE Plan di project? Lampirkan HSE Plan
If answer to Question above was no, briefly describe how you ensure that the required HSE
Systems are communicated and implemented on time.
Jika jawaban anda Tidak, Jelaskan bagaimana anda memastikan K3 dan Lindungan
Lingkungan yang disyaratkan dapat terkomunikasi dan dilaksanakan dengan baik.

Please Attach: HSE Plan or HSE Project program & Execution

Answer:

2. Do you have HSE Meetings? Please describe various of such meeting

Apakah anda mempunyai rapat HSE? Jelaskan beberapa meeting yang dilaksanakan

Please Attach: HSE Meeting procedure, program & Implementation

Answer:

3. Does your Company have written HSE procedures & HSE Program?
Apakah perusahaan anda mempunyai prosedur HSE & HSE Program?

Please Attach: Master List Procedure & HSE Program, Monitoring Procedure & Program

Answer:
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 Safety, Health and Environment Management Systems

SUB-CONTRACTOR’S SAFETY, HEALTH AND ENVIRONMENT Rev : 1

PRE-QUALIFICATION / ASSESSMENT QUESTIONNAIRE
Date : 3 Jan 2018

Section 4: HSE Training

Section 4: Pelatihan HSE
1. Do you have a HSE Training Matrix for your employees? Please attach HSE training matrix
or sample training plan that have be done and attendance list.
Apakah perusahaan anda mempunyai rencana pelatihan HSE untuk karyawan anda?
Silahkan melampirkan training matrix atau contoh rencana pelatihan yang sudah dilakukan
dan daftar hadir peserta.

Please Attach: Training Procedure & Training Matrix program & Implementation

Answer:

2. Do you have a formal training program(s) for Supervisors their responsibilities in HSE
Management as Supervisors?
Apakah perusahaan anda mempunyai program training untuk safety supervisor?

Please Attach : HSE Training for Supervisor above.

Answer:

3. Do you have a formal HSE Orientation Program for new employees? Please attach
attendance list and sample material orientation.
Apakah perusahaan anda mempunyai Program Safety Orientation untuk karyawan baru?
Lampirkan daftar hadir dan materi safety orientasi.

Please Attach: training certificate & Induction programs.

Answer:

Section 5: Managing HSE - Accident Performance Measurement

Section 5: Pengaturan HSE - Pengukuran Kinerja Kecelakaan
1. Do you keep Accident/ Incident Statistics for your Employees? Please provide your statistical
HSE Performance for 3 last years:
Apakah perusahaan anda menyimpan statistik kecelakaan terhadap karyawan anda? Mohon
disediakan Statistik 3 tahnu terakhir

Please Attach: Overall HSE Statistic & Definition

Answer:

2. Do you have a procedure for the investigation, reporting and follow-up of accidents,
dangerous occurrences or occupational illnesses? please attach also implementation program
and how to communicate to your employees if any incident happened
Apakah anda mempunyai prosedur untuk investigasi, pelaporan, dan tindak lanjut insiden,
kejadian berbahaya atau penyakit ditempat kerja ? Mohon dilampirkan juga implementasi
program dan bagaimanakah cara mengkomunikasikan terjadinya kecelakaan kepada para
karyawan

Please Attach: Investigation Procedures, reports and incidents follow up

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 Safety, Health and Environment Management Systems

SUB-CONTRACTOR’S SAFETY, HEALTH AND ENVIRONMENT Rev : 1

PRE-QUALIFICATION / ASSESSMENT QUESTIONNAIRE
Date : 3 Jan 2018

Answer:

Section 6: Personnel Protective Equipment

Section 6: Alat Pelindung Diri
1. What arrangements does your company have for provision and distribution of protective
equipment and clothing, both standards issue, and that required for specialized activities?
Pengaturan apa yang dimiliki perusahaan anda untuk pengadaan dan pemberian alat
pelindung dan pakaian kerja, baik yang standar maupun yang diperlukan untuk kegiatan-
kegiatan khusus?

Please Attach: PPE Procedure, PPE Stock Records and maintenance

Answer:

2. Do you provide appropriate personal protective equipment (PPE) for your employees?
Please provide a listing of the PPE for the scope of this work?
Apakah perusahaan anda menyiapkan alat pelindung diri untuk karyawan perusahaan anda?
Silahkan list alat pelindung diri yang akan anda siapkan untuk pekerjaan ini?

Please Attach: List Standard PPE, PPE Matrix & distribution

Answer :

3. Do you provide training on how to use PPE? Explain the content of the training and any
follow up?
Apakah anda memberikan pelatihan mengenai cara menggunakan PPE? Jelaskan materi
pelatihan dan setiap tindak lanjutnya.

Please Attach: Training Material, attendant list

Answer :

Section 7: Environmental & Hazards Management

Section 7: Lingkungan & Pengaturan Bahaya
1. Do you measure environmental performance?
Apakah perusahaan anda mengukur performance lingkungan?

Please Attach: Environment Procedure, evidence of the monitoring program

Answer:

2. Who is the person in charge for coordinating environment matter and what is he/she
experience?
Siapa yang bertanggung jawab dalam menangani untuk melakukan perlindungan lingkungan
di perusahaan anda dan apa pengalaman orang tersebut?
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 Safety, Health and Environment Management Systems

SUB-CONTRACTOR’S SAFETY, HEALTH AND ENVIRONMENT Rev : 1

PRE-QUALIFICATION / ASSESSMENT QUESTIONNAIRE
Date : 3 Jan 2018

Please Attach: HSE Orchart, CV Enviro specialist, Job Des & Qualification

Answer:

3. What systems are place for identification, classification, minimization and management of
waste?
Sistim apa yang ada untuk identifikasi, klasifikasi, pengurangan dan penaganan limbah?

Please Attach: procedures, program & implementation

Answer:

4. Does your company manage hazardous and toxic Material (B3), and B3 waste (including
waste lubricant/ oil, paint, thinners)? Provide procedure and evidence hazardous waste
manifest.
Apakah perusahaan saudara melakukan pengelolaan B3, dan penanganan limbah B3
(termasuk sisa minyak pelumas /oli, cat, thinner)? Berikan prosedur dan bukti manifest limbah
B3.

Please Attach: Procedure, program & implementation

Answer:

5. Do you have procedures for spill/leak reporting?

Apakah anda mempunyai prosedur pelaporan tumpahan/kebocoran?

Please Attach: Reports procedure, sample of spill kits

Answer:

Section 8: Drugs & Alcohol Program

Section 8: Program Alkohol & Obat-obatan Terlarang
1. Do you have a drugs and alcohol policy/procedure in your organisation? If yes please attach.
If No, how do you ensure that your employees do not use drugs and alcohol during project.
Apakah perusahaan anda mempunyai kebijakan pelarangan menggunakan obat dan
minuman terlarang? Jika Ya silahkan lampirkan.
Jika Tidak, bagaimana perusahaan anda memastikan karyawan anda tidak menggunakan
obat dan minuman terlarang selama project berjalan.

Please Attach: Policy & Procedure, socialization, sanction, (ref pages).

Answer:

Section 9: Emergency Response Procedure

Section 9: Prosedur Tanggap Darurat
1. Do you have an emergency response plan?
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 Safety, Health and Environment Management Systems

SUB-CONTRACTOR’S SAFETY, HEALTH AND ENVIRONMENT Rev : 1

PRE-QUALIFICATION / ASSESSMENT QUESTIONNAIRE
Date : 3 Jan 2018

Apakah anda mempunyai rencana tanggap darurat?

Please Attach: Procedures, Program & Implementation

Answer:

SECTION 10: Safety Achievement or Rewards

Section 10: Raihan atau Penghargaan
1. Please provide any significant achievements or awards?
Lampirkan penghargaan safety yang pernah didapat, jika ada.

Please Attach: HSE certification, HSE certificates/Awards

Answer:

I understand, follow all the requirement and all the answer above is correctly and
honest,
Saya mengerti, mengikuti semua persyaratan dan menjawab semua pertanyaan diatas
dengan jujur dan benar.

Signs,

( )
Director / Direktur
Date: