CORPORATE FORM

Element 9 : System Control , Measurement And

Continuous Improvement

Audit & Asseesment Questionnaire

Auditee PT. Projectika Studio Audit location

Audit date Audit Contact Audit no
Lead Auditor Audit Time Audit Standart

Ranking Result
Section Requirement Verification Comment
0 - 12 A/B/C/D
SECTION 1 : LEADERSHIP AND COMMITMENT
1. Commitment to HSE through leadership
a How are senior managers personally involved in HSE Highly involved in risk management,safety impact and work
management? environment in a project, also directly involved to ensure
HSE activity applied in all organization element bottom to
top.

b Provide evidence of commitment at all levels of the organization?

Distribute duty to all element in every level of organization,
basically each element's duty would be explained thoroughly.

c How do you promote a positive culture towards HSE matters?

Positive culture cultivated by delivering warning nicely and with
respect, provide HSE signs ( ex. with poster)

SECTION 2 : POLICY AND STRATEGIC OBJECTIVE

2.1. HSE Policy and Document
a Does your company have an HSE policy document?
HSE document attached
b Who has overall and final responsibility for HSE in your organization? Director is most responsible over all activities in this work.
Organization Structure attached
c Who is the most senior person in the organization responsible for this HSE Head department Structure Organization attached
policy being carried out at the premises and on site where his responsible to supervise all activities given to each element.
employees are working?

Audit Asseesment Questionnaire Page 1 of 8

2.2. Availability of PolicyStatement to Employees
Itemize the methods by which you have drawn your policy statement
to the attention of all your
employees Methods applied to drawn policy to all employee:
1. Explain all risk in every activity.
a 2 Mandatory daily,weekly, and mothly HSE activities.
3 Supervise HSE department in each element.
sample document attached.

b What are your arrangements for advising employees of changes in Arragements in advertising changes .
the policy? 1. Changes reviewed along with all senior member of all
departments with the intention of the changes well accepted to
all departments and still capable to applied according to every
departments ability.
2 Advertise to all elements through HSE.
SECTION 3 : ORGANIZATION, RESPONSIBILITY, RESOURCES, STANDARD AND DOCUMENTATION
3.1. Organization - Commitment and Communication
a How is management involved in HSE activities, objective setting and
monitoring? To encourage management's involvement in HSE Activities,
Senior HSE officer inform and report regularly on all HSE
activities about health,safety and enviroment to minimize over
budget or unexpected funds.

b Do you have a safety organization? Yes , Attached

c How Is your company structured to manage and communicate HSE

effectively? Managing and Comunnicating HSE effectively achieved by:
1. List of Activity from each element.
2. HSE Department ensure and supervise each activities related
to health,safety and security.
Activity Form attached

3.2. Competence and Training of Manager/ Supervisor/ Senior Site Staff/ HSE Adviser
Have the managers and supervisors at all levels that will plan, During special training only senior HSE officer attend, then all
monitor, oversee and carry out the work received formal HSE training materials obtained during training advertise to all element in
a in their responsibilities with respect to conducting work to HSE accordance to SOP approved by HSE Department and
requirements? Management.

3.3. Competence and General Training

a What arrangements does your company have to ensure employees Advertising information related to health,safety, security and
have knowledge of basic industrial HSE, and to keep this knowledge environment impact in mandatory schedule which is at the
up to date? beginning of the week. Safety talk Documentation

b What arrangements does your company have to ensure new Arrangements for new employees and sub contractors
employees, including sub contractors, also have knowledge of your 1. Including health,safety,and security aspects in every activity
HSE policies and practices? submission ( including personal protective equipments and
security level in accordance to the actvity).
2. Inform environment impact (in example noise and waste).

Audit Asseesment Questionnaire Page 2 of 8

 What arrangements does your company have to ensure new We believe our arrangements as explained above ( question
employees and new subcontractor employee have been instructed 3.3.b.) already well instructed information needed according to
and have received information on any specific hazards arising out of our company requirements for new employee and sub
c the nature of the activities? What training do you provide to ensure contractors need to be informed.
that all employees are aware of company requirements?

What arrangements does your company have to ensure existing staff Our existing HSE officer knowledge listed during recruitment in
HSE knowledge is up to date? If training is provided in-house please resume and legal proved certification, continued with practical
d give details of content skill test in health and safety.

3.4. Specialize Training

a How have you identified areas of your company's operations where In our area of company, we do not require special training to deal
specialized training is required to deal with potential hazards? Please with potential hazard.
itemize and
provide details of training given
b If the specialized work involves radioactive, asbestos removal, In our area of company, we do not require special training to deal
chemical or other occupational health hazards, how are the hazards with those hazards stated in the question.
identified, assessed and controlled?

3.5. HSE Qualified Staff - Additional Training

Does you company employ any staffs that posses HSE qualifications
c that aim to provide training in more than the basic requirements? Yes, we recruited employee qualified in HSE.

d What format of safety qualifications does your staff have? Describe "Ahli Madya" qualified HSE officer
Certification Attached
3.6. Assessment Suitability of Sub Contractors/ Other Compaies
How do you assess: HSE competence and HSE record of the
Assesment of all HSE Competence and record based on
subcontractors and companies with
health,safety and security policy in our company.
a whom you place contract
Contract Agreement between Task Master (Director main
contractor) Task Receiver (director Sub Contractor)
b Where do you spell out the standards you require your contractors to
meet? 1. Drawing Plan Explanation
2. Working Methods by Sub Contractor
3. Explaination on health,safety and security aspects.

c How do you ensure these standards are met and verified?

These standards met and verified by:
1 Results reviewed by all departments involve being approved
2. All aspects of health,safety and security analized and
approved.
d Please provide the names of major sub-contractor, if known, at this
time
Sub -contractor has not been appointed yet.

Audit Asseesment Questionnaire Page 3 of 8

3.7. Standard
a Where do you spell out the HSE performance
standards you require to be met? Ensuring HSE aspects fulfilled and distributed to all elements
met the requirements done by:
1. All activity report always includes HSE Aspect
2. Safety talk dan supervise activities on the field
3. Make sure all activities proceed strictly according to HSE
aspects.

b How do you ensure these are met and verified? We have HSE departments that consist of fields officer up to
HSE Manager as the person responsible.

How do you identify new industry or regulatory standards that may be

c applicable to your activities? Informed by related department.

d Is there an overall structure for producing, updating

and disseminating standards? Standards usually determined at the beginning of projects. If
updates or any changes required will be advertise during safety
talk to all elements.

e List your HSE procedures manuals. Please submit

current copies Document Attached

SECTION 4; HAZARDS AND EFFECT MANAGEMENT

4.1. Hazards anf Effect Management
What techniques are used within your company for the identification,
assessment, control and mitigation of hazards and effects? 1. Activity explanation and implementation done by paying
a attention to all risk.
2. Analize HSE Activities on risk and impact .

4.2. Exposures of the Workforce

a What systems are in place to monitor the exposure of your workforce
to chemical or We monitor the exposure with identification system and review
by qualified officer.

4.3. Handling of Potencial Hazards

a) How is your workforce advised on potential hazards, e.g.
chemicals, noise, radiation, etc., encountered in the course of their 1. Distribute according to identification result.
a work? 2. Procure safety from environment impact according to
analization result provided by expert team.

4.4. Personnel Protective Equipment

What arrangements does your company have for provision and Policies in monitoring equipment:
unkeep of protective equipment and clothing, both standards issue, 1. Checklist on equipment checking before use.
a and that required for specialized activities? 2. List on Isolated Equipment (damage ones)

b Do you provide appropriate Personal Protective Equipment (PPE) for Personel Protectives Equipment
your employees? Please provide a listing of the PPE for the scope of List of PPE Attached
this work

Audit Asseesment Questionnaire Page 4 of 8

 Do you provide training on how to use PPE? Explain the content of PPE training
the training and any follow-up!
1. Explanation on how to use and advantages on using.
c 2. Poster about steps to use PPE according to standard.
3. Poster/sign to advertise PPE requirements.
Poster Example Attached
d Do you have a program to ensure that PPE is impacted and
Using poster to show risk and impact
maintained?
PPE Required Poster Attached
4.5. Waste Management
What systems are placed for identification, Waste Management sistem:
classification, minimization and management of waste? 1. Waste management conducted by regularly distributing
outside project site.
2. Human Waste management conducted by absorbtion
a
(fabricated or custom).
3.Activities Waste management for example dirt and noise
conducted by advertising it with neighbor s and head of
neighbor.
resulting in environmental damage in the amount greater than USD
b 10,000 for the last 24 months. There isn't any.

c Do you have procedures for waste disposal? Attached

d Do you have procedures for spill reporting? Attached
4.6. Industrial Hygiene
a Do you have an industrial hygiene program? Attached
Do you have a risk assessment, or similar type effort, Conducted by observing and analizing by activity plan policy and
for identifying work place hazards? Please describe this process methods.

If you introduce hazardous materials/substances into the work site,

c describe the process you will use to There isn't any.
document and control these?
4.7. Drugs and Alcohol
Do you have a drugs and alcohol policy in your organization? If so, We forbid any elements to bring any alcohol related things
does it include pre-employment and/or employees under influence.
and random testing?
a

SECTION 5 : PLANNING AND PROCEDURES

5.1. HSE or Operational Manuals
Do you have a company HSE manual or Operations Manual with Attached.(included in section 3 attachments)
relevant sections on HSE which describes in detail your company
approved HSE working practices and safety instructions such as
a those covering scaffolding, lifting, heavy equipment, pressurized
cylinders or excavation?

Audit Asseesment Questionnaire Page 5 of 8

 b How do you ensure that the working practices and procedures used Review all report on activities related with HSE and field
by your employees on-site are consistently in accordance with your inspection.
HSE policy objectives and arrangements?

5.2. Equipment Control and Maintenance

How do you ensure that plant and equipment used within your Review on equipment monitoring report
premises, on-site, or at other locations by your employees are review on maintenance equipment report.
correctly registered, certified with regulatory requirement, inspected, Isolated equipment maintenance form attached
a controlled and maintained in a safe working condition?

5.3. Transport Safety Management Maintenance

a What arrangement does your company have for vehicle incidents In the beginning of projects already stated that all vehicle must
prevention? be according to standard required in the project site. For incident
outside project site usually cooperated with related agency (ex.
traffic police)

SECTION 6 : IMPLEMENTATION AND PERFORMANCE MONITORING

6.1. Management and Performance Monitoring of Work Activities
What arrangement(s) does your company have for supervision and HSE Performance showed by the amount of incident occurred in
monitoring of HSE performance? project site.If the amount is minimum or zero loss or ther is no
a
unpredicted budget needed, it is considered that HSE SOP run
well in the field.
b What type of performance criteria are used in your company? give
examples: Document attached

c Has your company received any award for HSE performance

achievement? Not yet

6.2. Safety Program

a Do you organize in-house safety meetings?
Yes (Schedule and Form Attached)
b Do you organize campaigns to stimulate safe working practices?
Yes. Safety Talk held whole-heartedly but with foods to stimulate
employees.

6.3. Statutory Notifiable Incidents/ DangerouseOccurence/ Improvement Requirement and Prohibition Notice
Has your company suffered any improvement requirement or No
prohibition notices on statutory notifiable incidents/dangerous
occurrences by the relevant national body, regulatory body for HSE
or other enforcing authority or been prosecuted under any HSE
a legislation in the last five years?

6.4. HSE Performance Record

a Have you maintained records of your incidents and HSE performance
for the last five years?

 Number of Fatalities
There isn't any

Audit Asseesment Questionnaire Page 6 of 8

  Lost Time Injuries
There isn't any

 Lost Workday Cases

There isn't any

 Medical Treatment Cases

There isn't any

 Restricted Work Day Cases

There isn't any

 Fatal Accident Rate

There isn't any

 Lost Time Injury Frequency

There isn't any

 Total Recordable Incident Rate for each year There isn't any
b How is health performance recorded?
Checked Regularly
c How is environmental performance recorded? Providing opportunities for youngster from neighbor to contribute
in any work. Or providing any temporary facilities caused by
change influenced by project.

d How often is HSE performance reviewed? By whom? Site supervising carried by HSE Officer applied to all employees
from top to bottom in organization in order to run according to
SOP.

6.5. Incident Investigation and Reporting

a Do you have a procedure for the investigation, reporting and follow- Attached(inckuded in section 3 attachements)
up of accidents, dangerous occurrences or occupational illnesses?

How are the findings following an investigation, or a relevant incident Informed to all elements if any issued /incident happen and
occurring elsewhere, communicated to your employees? anticipation step so it would not reoccured.
b

c Are near miss safety learning reported?

During safety talk miss-safety reported were given warn and
elevated warn to give deterrent effect.

d Please provide copies of investigation reports for the last 12 months! Attached

SECTION 7 : AUDIT AND REVIEW

a Do you have a written policy on HSE auditing?
Knowledge grow according to inputs and new methods.

How does this policy specify the standards for auditing, including Help work implementation because there is incident
b unsafe act auditing and the management that help minimize accident and environment
qualifications for auditors? impact.

Audit Asseesment Questionnaire Page 7 of 8

 c Do your companies HSE Plans include schedules for
auditing? Yes, done as reference and improvement HSE aspects.

SECTION 8 : EMERGENCY RESPONSE PROCEDURE

a Attached
Do you have a emergency response plan

Describe how emergency preparedness is maintained and the HSE Department provides structure in case of emergency by
command structure in case of emergency providing field officer to senior manager, Emergency Room, up
to nearest fire extinguisher analize from the beginning of project.
For emergency we provided emergency room that accommodate
patient bed,first aid kit, and patient stretcher.
b

SECTION 9 : HSE MANAGEMENT ADDITIONAL FEATURES

a Describe the nature and extent of your company's participation in Procurement and Construction Service
relevant industry, trade, and governmental organizations? 1. Design & Build Construction
2. Office and Residential Renovation
3. Interior Design dan Exsterior Design

Score Indicator :
A : 0 ==> No. procedures and need to be
build (SMS)
B : 4 ==> Procedure exist but there is no
evidence or implementation
C : 8 ==> Procedure exist but
Implementation not consistence
D : 12 ==> Procedure and Implementation
Inline

Audit Asseesment Questionnaire Page 8 of 8