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Residual Risk Level Step & Activities Hazard, Env. Aspect Risk, Env. Impacts Resiko Dan

This document is a job safety analysis (JSA) form for a contractor working at PT. Wina Gresik. It records the contractor's name, work location, start and end dates of the project, and signatures of those involved in the project. The form includes 9 steps of the work and for each step lists potential hazards, initial and residual risk levels, actions planned to control risks, and target dates for completing those actions. It will be used to identify risks and ensure safety protocols are followed over the course of the project.

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Iwan Raya
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65 views1 page

Residual Risk Level Step & Activities Hazard, Env. Aspect Risk, Env. Impacts Resiko Dan

This document is a job safety analysis (JSA) form for a contractor working at PT. Wina Gresik. It records the contractor's name, work location, start and end dates of the project, and signatures of those involved in the project. The form includes 9 steps of the work and for each step lists potential hazards, initial and residual risk levels, actions planned to control risks, and target dates for completing those actions. It will be used to identify risks and ensure safety protocols are followed over the course of the project.

Uploaded by

Iwan Raya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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EHS STANDART FORM RECORD NO.

FORM OF JOB SAFETY ANALYSIS (JSA) FOR CONTRACTOR REVISION NO.


FORMAT JOB SAFETY ANALYSIS (JSA) UNTUK CONTRACTOR ISSUED DATE
PT. WINA GRESIK CONTRACTOR : CV. DWI TEHNIK PERSADA WORK LOCATION : .............................................. PAGE
JOB TITTLE : START OF PROJECT : END OF PROJECT :

Prepared by : Confirmed by : Acknowledge by : Approved by :

................./Spv of Contractor ................./Safety <Contractor> ................./Spv PRJ or Plant ................./HoD EHS


................./HoD PRJ or Plant
INITIAL RISK LEVEL RESIDUAL RISK LEVEL

CONSEQUENCE

CONSEQUENCE
PROBABILITY

PROBABILITY
ACTIONS PLAN FOR RISKS CONTROL DUE DATE
STEP & ACTIVITIES HAZARD, ENV. ASPECT RISK, ENV. IMPACTS RESIKO DAN PIC
NO RENCANA TINDAKAN UNTUK (JADWAL
TAHAP DAN KEGIATAN BAHAYA DAN ASPEK LINGK. DAMPAK LINGKUNGAN (TGG-JWB)

#RISK

#RISK
PENGENDALIAN RESIKO SELESAI)

NO NO (H, M, L) (H, M, L) (H, M, L) NO (H, M, L) (H, M, L) (H, M, L)


1 Persiapan peralatan &
material

2 Penggalian tanah

3 Pembesian

4 Bekesting

5 Pengecoran

6 Pasang bata

7 Pasang kusen

8 Pasang atap

9 Pengecatan

* Baris di bawah ini khusus untuk lembar terakhir saja RISK ASSESMENT MATRIK:

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