No. : CV/F/014 Date : 08.07.

14
Page : 1 of 2 Isssue :2
Reference: : ZSD05 – Occupational Safety Revision :4

HASIL IDENTIFIKASI BAHAYA/ASPEK LINGKUNGAN DAN PENILAIAN RISIKO/DAMPAK

RESULT OF HAZARD-ENVIRONMENTAL ASPECT IDENTIFICATION AND RISK/IMPACT ASSESSMENT

Plant : Area Kerja : Proses/Aktivitas :

Kondisi : Normal *) Abnormal *) Darurat (Emergency) *)

*) Coret yang tidak berlaku/ tidak relevan

Tanggal :
Tahap I Tahap II

E & HS E & HS
Tindakan Kontrol Yang Ada untuk Risiko Action Plan Status
Matrix* Matrix**
Bahaya K3 & Dampak LH (Existing Control
Further
Measures for HS Hazard Risk & E Impact)

Risk/ Impact
Probability
Risk/Impact
Probabily
Bahaya K3 & Aspek LH (HS Hazard & E Risiko Bahaya K3 & Dampak LH (HS Action

(Residual)
(Existing)
Severity

Severity
No (Tuliskan tindakan kontrol sesuai dengan
Aspect) Hazard Risk & E Impact) Recommended further Completion
urutan langkah-langkah pengendalian PIC
measures date
risiko/dampak: 1. Eliminasi, 2. Substitusi, Yes No
3. Teknik, 4. Organisasi, 5. APD)

1. Eliminasi:
2. Substitusi:
3. Teknik:
4. Organisasi:
5. Alat Pelindung Diri (APD):

Anggota Tim Penilaian Risiko/Dampak ( Risk/Impact Assessor Team Membert)

No. Nama - Bagian Paraf No. Nama – Bagian Paraf No. Nama – Bagian Paraf No. Nama – Bagian Paraf No. Nama – Bagian Paraf
1. 2 3 4 5
Note:
E&HS Matrix* refer to E & HS assessment resulting magnitude of risk/impact at condition when the HIRA is performed.
E&HS Matrix** refer to E & HS assessment resulting magnitude of risk/impact after action plans are implemented.

Corporate EHS Indonesia