FORM/KI-TMS-P-03/014b

HEALTH, SAFETY, ENVIRONMENT

MANAGEMENT SYSTEM
Subcontractor HSE Pre-Qualification Questionnaire
Revision : 00 Effective date: 20-05-2019

FOR: MEDIUM – HIGH RISK LEVEL (SUPPLY & INSTALL)

Petunjuk Pengisian/ Fulfillment Instruction

1. Kuesioner ini terdiri dari 13 poin persyaratan utama yang harus dilengkapi
Questionnaire is consist of 13 main requirements
2. Poin no.8 (Operational Control) pengisian disesuaikan dengan ruang lingkup subkontraktor. Jika ada item yang tidak
sesuai maka dapat diberi keterangan not available
The 8th point (OperationalControl) is based on scope of subcontractor. If any un-appropriate item , it could be remark
not available
3. Selain poin no. 8 tersebut maka item harus dilengkapi atau diberi keterangan pada checklist Ada atau Tidak ada-nya
Except 8th point, all item should be completed.
1. GENERAL
1.1 Contractor Company Name PT Zeta Utama Satya
Nama Perusahaan Kontraktror
1.2 Contractor Address Jl. Panjang no. 808K Kampung Baru Sukabumi Selatan
Alamat Perusahaan Kontraktor Kebon Jeruk Jakarta Barat 11560
1.3 Contractor was founded (date) 1995
Tanggal berdiri Perusahaan Kontraktor
1.4 Service Provided
Bidang Jasa
1.5 Contractor Key Personnel Name of Company Director:
Pekerja Utama Nama Direktur Perusahaan: Zuhal Zaini
Phone : 0818742619
Email : [email protected] ; [email protected]
Name of Project Manager:
Nama Project Manager:
Phone :
Email :
Name of HSE Representative:
Nama HSE Manager/ Officer :
Phone :
Email :
2. SAFETY & HEALTH POLICY, LEADERSHIP & RESOURCES
Checklist Item Ada Tidak
2.1 Does your company have a health, Please provide copy
safety, environment policy and Lampirkan salinannya
management commitment that
signed by representative of Top
Management?
Apakah perusahaan anda memiliki R □
kebijakan komitmen manajemen
Keselamatan, kesehatan kerja dan
Lingkungan yang ditandatangani
oleh Top Management?
2.2 Is HSE policy communicated to all Please explain and provide evidence
employees and workers?
Apakah kebijakan K3L
R □
Jelaskan dan lampirkan buktinya

dikomunikasikan ke seluruh
karyawan dan pekerja ?
2.3 Does your company have any Please provide copy
certification related to HSE Lampirkan salinannya
management system such as ISO
45001, SMK3 PP.50 th 2012 or ISO
14001?
Apakah perusahaan anda memiliki
□ R
sertifikat terkait Sistem Manajemen
K3L seperti ISO 45001, SMK3,
ISO 14001?

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HEALTH, SAFETY, ENVIRONMENT

MANAGEMENT SYSTEM
Subcontractor HSE Pre-Qualification Questionnaire
Revision : 00 Effective date: 20-05-2019

2.4 Does your company have any other Please provide copy
certification management system
such as ISO 9001 or material
□ R Lampirkan salinannya

certification such as Proper, ISO

14001, FAKO or Green Label?
Apakah perusahaan anda memiliki
sertifikat lain terkait Sistem
Manajemen seperti ISO 9001 atau
terkait material seperti Proper, ISO
14001, FAKO atau Green Lable?
2.5 Do you have an annual HSE Please provide copy
objective and program?
Apakah perusahaan anda memiliki
□ R Lampirkan salinannya

sasaran / target dan program K3L

tahunan ?
2.6 Does your company have a full-time Please explain and provide organization chart
position
responsibilities?
assigned HSE R □
with clearly defined HSE responsibilities and
accountability for managers, supervisors,
Apakah perusahaan anda memiliki safety personnel and workers
jabatan tetap yang bertanggung Lampirkan organisasi chart lengkap dengan
jawab untuk K3L? job description terkait K3L baik bagi level
manager, supervisor dan juga pekerja
2.7 Does your company have a HSE Please provide copy of organization chart and
department?
Apakah perusahaan anda memiliki
R
contact person □
Lampirkan salinan organisasi chart dilengkapi
departemen K3L? dengan contact person
3. LIST OF LEGISLATION RELATED TO SAFETY, HEALTH, ENVIRONMENT
3.1 Does your company have a HSE- Please provide copy of regulation list and its
related government and local
regulation and its evaluation of
□ R
evaluation of compliance
Lampirkan salinan daftar regulasi dan evaluasi
compliance? pemenuhannya
Apakah perusahaan anda memiliki
daftar perundang-undangan terkait
K3L dan evaluasi pemenuhannya?
4. SAFETY, HEALTH, & ENVIRONMENT MANUAL AND GUIDELINES
4.1 Does your compony have a written Please provide list of procedures
HSE procedure?
Apakah perusahaan anda memiliki
R □
Lampirkan daftar prosedur

prosedur-prosedur K3L?

4.2 Does your compony have written Please provide the list of those safe work
safe work guideline specific for
your risky works (eg. Working at
R □ guideline and the copy
Lampirkan daftarnya dan salinannya masing-
height, lifting work, hotwork, masing
confined space, manual material
handling, heavy equipment
operation,electrical works, etc)?
Apakah perusahaan anda memiliki
panduan kerja aman (SOP / WI)
yang terkait secara spesifik terhadap
pekerjaan berisiko (seperti : Bekerja
di ketinggian, Pengangkatan,
Pekerjaan Panas, Bekerja di ruang
terbatas, Penanganan material
secara manual, Pengoperasian alat
berat, Pekerjaan kelistrikan, dll)?

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HEALTH, SAFETY, ENVIRONMENT

MANAGEMENT SYSTEM
Subcontractor HSE Pre-Qualification Questionnaire
Revision : 00 Effective date: 20-05-2019

4.3 Is there any another HSE guideline Please provide

(eg. Safety pocket book, magazine,
etc)?
□ R Lampirkan

Apakah ada panduan K3L lainnya

seperti Buku Saku K3L, majalah
K3L, dll?
4.4 Does your company create HSE - Please provide the copy of cover and
plan for your projects?
Apakah perusahaan anda membuat
R □ contents
- HSE plan shall be submitted prior to
safety plan untuk proyek ? construction commencement (2 weeks before)
- Lampirkan salinan cover dan daftar isinya
- *HSE plan harus sudah disubmit 2 minggu
sebelum pekerjaan dimulai
5. HIRADC & ASDAM
5.1 Does your compony have a written Please provide copy and evidence
hazard identification & risk
assessment procedure, aspect and
□ R Lampirkan salinan dan buktinya

impact, and its implementation?

Apakah perusahaan anda memiliki
prosedur identifikasi bahaya
(HIRADC) dan aspek-dampak
(ASDAM) serta contoh
implementasinya ?
5.2 Does your compony have a written Please provide copy
job safety analysis for the potential
riski works (eg. Lifting, hotworks,
R □ Lampirkan salinannya

working at height, confined space,

loading-unloding by manual
handling/machineries, etc)
Apakah perusahaan anda memiliki
lembar JSA (job safety analysis)
untuk pekerjaan yang berisiko
tinggi dan analisa dampak
lingkungan dari pekerjaan?
5.3 Does your company hold tool box Please provide evidence
meeting to explain hazards and risk
prior to work ?
R □ Lampirkan buktinya

Apakah perusahaan anda

mengadakan kegiatan TBM (tool
box meeting) untuk menjelaskan
bahaya dan risiko sebelum bekerja ?
6. TRAINING & COMPETENCY
6.1 Does your compony have a written Please provide copy
training & competency procedure?
Apakah perusahaan anda memiliki
R □ Lampirkan salinannya

prosedur pelatihan dan kompetensi

K3L?
6.2 Is there training matrix Please provide copy
documented?
Apakah ada matriks training ?
□ R Lampirkan salinannya

6.3 Does your company have a list of Please provide evidence (table of competency
mandatory competency for specific
works (e.g. Construction technician
□ R & copy of certificates or license)
Lampirkan buktinya (daftar kompetensi dan
expert, Electrical safety expert, salinan sertifikat atau SIO)
welder license, crane operating
license, first aider, etc)

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HEALTH, SAFETY, ENVIRONMENT

MANAGEMENT SYSTEM
Subcontractor HSE Pre-Qualification Questionnaire
Revision : 00 Effective date: 20-05-2019

Apakah perusahaan anda memiliki

daftar kompetensi untuk pekerjaan
secara spesifik (seperti : Ahli K3
konstruksi, Ahli K3 listrik, SIO
welder, SIO Operator Crane, First
aider, dll) ?
6.4 Does your company have a HSE Please provide evidence
training program (including safety,
health and environment orientation
□ R Lampirkan buktinya

program/HSE induction and

campaign for jobsite personnel)?
Apakah perusahaan anda memiliki
program pelatihan K3L kepada
pekerja (termasuk orientasi bagi
pekerja baru dan campaign)?

7. COMMUNICATION, PARTICIPATION & CONSULTATION

7.1 Does your company have a written Please explain and provide evidence
communication, participation &
consultation procedure?
□ R
(program/schedule, minutes & attendance list)
Lampirkan salinannya (contoh
Apakah perusahaan anda memiliki program/schedule, minutes meeting dan daftar
prosedur komunikasi, partisipasi hadir)
dan konsultasi (terkait K3L)?
7.2 Does your company hold periodic Please explain and provide evidence
HSE meeting?
Apakah perusahaan anda
R □
(program/schedule, minutes & attendance list)
Lampirkan salinannya (program/schedule,
mengadakan rapat K3L secara minute meeting dan daftar hadir)
berkala?
7.3 Are the means of communication Please explain and provide evidence
media containing the HSE
information provided (e.g. Internet
R □
Jelaskan dan lampirkan buktinya

media, information board, bulletin,

etc)?
Adakah fasilitas media informasi terkait
K3L tersedia (seperti: media internet,
papan informasi, bulletin K3, dll)?
7.4 Have your company conducted Please explain and provide evidence
relevant communications to
external interested parties (eg.
□ R Jelaskan dan lampirkan buktinya

Manpower department,hospital, fire

dept, legal publisher, etc)?
Apakah perusahaan anda menjalin
komunikasi dengan pihak external
yang terkait seperti :
- Wajib Lapor Pekerjaan/ Proyek
Konstruksi Bangunan ke
Depnaker
- Izin Lingkungan ke BPLHD
- Pelaporan P2K3 ke Depnaker
- Kerjasama Rumah Sakit
terdekat
- Koordinasi dengan Damkar
Terdekat
- Akses Penerbit Legal K3L
- dll

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HEALTH, SAFETY, ENVIRONMENT

MANAGEMENT SYSTEM
Subcontractor HSE Pre-Qualification Questionnaire
Revision : 00 Effective date: 20-05-2019

7.5 Participation of employees & Please explain and provide evidence

workers in appropriate involvement
in creating HIRADC,ASDAM,
□ R Jelaskan dan lampirkan buktinya

incident investigation, review of

policy or HSE objectives
Partisipasi karyawan dan pekerja
dalam keterlibatan yang tepat
seperti pembuatan HIRADC,
ASDAM, investigasi insiden,
peninjauan kebijakan atau sasaran
dan program K3L

8. OPERATIONAL CONTROL
8.1 Does your company have a written Please provide copy and evidence
purchasing procedure to control
related to purchased goods and
R □ Lampirkan salinan buktinya

equipment?
Apakah perusahaan anda memiliki
prosedur purchasing yang mengatur
pembelian material dan pengadaan
alat-alat sesuai standar kerja?
8.2 Does your company have a written Please provide copy and evidence
procedure to handle waste of
material or equipment operation?
□ R Lampirkan salinan buktinya

Apakah perusahaan anda memiliki Jika tidak ada prosedur tertulis, informasikan
prosedur penanganan terhadap cara penanganan yang dilakukan terkait
limbah yang dihasilkan dari limbah yang dihasilkan
pemakaian material/ alat?
8.3 Does your company have a written Please provide copy and evidence
procedure to control subcontractor,
others visitor atau vehicles?
£ R Lampirkan salinan dan buktinya

Apakah perusahaan anda memiliki

prosedur untuk mengendalikan
subcontractor, pengunjung proyek
dan kendaraan proyek?
8.4 Do you evaluate the ability of Please explain and provide evidence
subcontractor to comply with
applicable HSE requirements as
R □ Jelaskan dan lampirkan buktinya

part of your process?

Apakah perusahaan anda
mengevaluasi subcontractor untuk
mematuhi ketentuan K3L sebagai
bagian dari proses pemilihan ?
8.5 Does your company have a written Please provide copy and evidence
procedure to control permit to work
for risk activities?
R □ Lampirkan salinan dan buktinya

Apakah perusahaan anda memiliki

prosedur tertulis untuk mengontrol
izin kerja bagi aktivitas berisiko ?
8.6 Does your company provide the Please explain and provide copy of PPE
required personal protective
equipment (PPE) for the jobs you
R □ matrix and the evidence
Jelaskan dan lampirkan salinan matrix
perform? penggunaan APD dan buktinya
Apakah perusahaan menyediakan
APD yang diperlukan untuk
pekerjaan yang dilakukan ?

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HEALTH, SAFETY, ENVIRONMENT

MANAGEMENT SYSTEM
Subcontractor HSE Pre-Qualification Questionnaire
Revision : 00 Effective date: 20-05-2019

8.7 Do you conduct, document and Please explain and provide evidence
follow up inspections on operating
equipment (e.g., cranes, excavators,
□ R Jelaskan dan lampirkan buktinya

etc) before on-site, pre-operation or

periodic?
Apakah perusahaan anda
melaksanakan, mendokumentasikan
dan menindaklanjuti pemeriksaan /
inspeksi pada peralatan operasi
(misalnya crane, excavator, dll) baik
sebelum on-site, pra-operasi atau
berkala?
8.8 Do you maintain operating Please explain and provide evidence
equipment in compliance with
regulatory requirements including
□ R Jelaskan dan lampirkan buktinya

certification, calibration,
maintenance system, etc?
Apakah perusahaan mengelola /
memelihara peralatan operasi
dengan mematuhi ketentuan dari
badan berwenang termasuk
sertifikasi (SILO), kalibrasi, sistem
perawatan, dll?
8.9 How do you control that jobsite Please explain and provide evidence
personnel and vehicles entering the
project meet the on-site HSE
□ R (eg.,project ID card, security control, etc)
Jelaskan dan lampirkan buktinya (misal ID
regulation? card proyek, kontrol security)
Bagaimana perusahaan anda
mengendalikan pekerja proyek atau
kendaraan yang memasuki proyek
telah memenuhi persyaratan tata
tertib K3L di proyek?
8.10 How do you implement site Please explain and provide evidence
protections to control the existing
hazards at project (e.g., falling
R □ (eg.,photos at your projects)
Jelaskan dan lampirkan buktinya (dengan
hazard, falling object, fire, photo)
electrocution, struck by vehicles, Pengisian JSA dan Toolbox meeting sebelum
etc? bekerja
Bagaimana perusahaan anda
mengaplikasikan proteksi untuk
mengontrol bahaya yang ada di
proyek (seperti jatuh dari
ketinggian, benda jatuh, kebakaran,
tersetrum, tertabrak kendaraan
proyek?
8.11 Do you use/store hazardous Please provide copy of registered materials
materials for your activities ?
Apakah perusahaan anda
□ R for hazardous materials
Lampirkan salinan daftar material B3 yang
menyimpan/menggunakan material digunakan
B3?
8.12 Does your company have a Please provide copy and evidence
procedure to arrange waste
hazardous material and emission
□ R Lampirkan salinan dan buktinya

control ?
Apakah perusahaan anda memiliki
prosedur yang mengatur
pembuangan limbah material B3

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MANAGEMENT SYSTEM
Subcontractor HSE Pre-Qualification Questionnaire
Revision : 00 Effective date: 20-05-2019

(bahan beracun dan berbahaya) dan

pengendalian emisi ?
8.13 Does your company have a Please provide evidence (letter of agreement
authorized transporter to manage
your hazardous waste material ?or
□ R from authrorized transporter and permit from
government, disposal forms, etc)
conduct hazardous and toxic waste
handling autonomously?
Apakah perusahaan anda memiliki
vendor untuk pengangkutan limbah
material B3? Atau perusahaan
melakukan penanganan sendiri
terhadap limbah B3?
9. HEALTH AND HYGIENE
9.1 Does your company have a process Please explain and provide evidence
to provide medical treatment for
your employees & workers
R □ Jelaskan dan lampirkan buktinya
Asuransi Manulife
(eg.,Clinic, insurance)?
Apakah perusahaan anda memiliki
proses untuk memberikan
perawatan medis bagi karyawan dan
pekerja (Klinik proyek, Kerjasama
Rumah sakit dan Asuransi
Kesehatan) ?
9.2 Does your company conducted Please provide evidence
medical exams for employee for
pre-placement job capability or
□ R Lampirkan buktinya

periodic medical check-up service?

Apakah perusahaan anda
mengadakan test MCU bagi calon
karyawan sebelum penempatan atau
mengadakan MCU secara berkala
MCU bagi karyawan ?
9.3 Does your company have a Please explain and provide evidence
program to control health aspect of
canteen crews (if canteen provided
□ R Jelaskan dan lampirkan buktinya

at project area) and competency of

food handler?
Apakah perusahaan anda memiliki
program untuk mengontrol aspek
kesehatan juru masak kantin (jika
perusahaan anda menyediakan
kantin di dalam proyek) dan
sertifikat penjamah makanan?
9.4 Do you perform workplace Please explain and provide evidence
monitoring at your workplace (e.g.,
physical;temperature/noise/lighting
□ R Jelaskan dan lampirkan buktinya

, chemical;
CO/CO2/SO2/PDS/Particulate and
biological; bacteria in the air)?
Apakah perusahaan melaksanakan
pemantauan lingkungan kerja (misal
pengukuran lingkungan kerja
fisika ; suhu /
kebisingan/pencahayaan, dll,
kimia ;CO/CO2/SO2/PDS/Partikulat
/ dan biologi ; kandungan bakteri di
udara) ?

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HEALTH, SAFETY, ENVIRONMENT

MANAGEMENT SYSTEM
Subcontractor HSE Pre-Qualification Questionnaire
Revision : 00 Effective date: 20-05-2019

9.5 Does your company have a Please provide evidence

substance abuse & HIV AIDS
policy and program?
□ R Lampirkan buktinya

Apakah perusahaan anda memiliki

kebijakan dan program pemantauan
penyalahgunaan bahan / obat-obatan
terlarang dan HIV Aids?
9.6 Does your company have a written Please provide copy and evidence
procedure to control chemical □
substance, and to maintain updated
R Jelaskan dan lampirkan buktinya

and accessible MSDS (material

safety data sheet) for paints and
chemical)?
Apakah perusahaan anda memiliki
prosedur untuk mengontrol bahan
kimia, dan menyediakan serta
memelihara MSDS (lembar
keselamatan bahan berbahaya)
untuk cat dan bahan kimia yang
digunakan ?
10. EMERGENCY PREPAREDNESS & RESPONSE
10.1 Does your company have a written Please provide evidence
emergency preparedness & R
response (EPR) procedure and EPR
£ Lampirkan buktinya

organization?
Apakah perusahaan anda memiliki
prosedur kesiapan-tanggap darurat
dan bagan organisasinya?
10.2 How is the procedure Please provide evidence
communicated to employees and
workers at project?
□ R Lampirkan buktinya

Bagaiman prosedur tersebut

disosialisasikan kepada seluruh
karyawan dan pekerja di area kerja?
10.3 Do you document emergency Please provide evidence
response training and drills?
Apakah perusahaan
□ R Lampirkan buktinya

mendokumentasikan pelatihan dan

uji coba tanggap darurat ?
10.4 Does your company have qualified Please provide copy of organization chart and
resources to handle emergency □
condition (eg., fire fighter, first
R list of resources with certification or
emergency license
aider, etc)? Lampirkan copy ERP organization chart dan
Apakah perusahaan anda memiliki daftar SDM disertai dengan sertifikasi /
sumberdaya yang memiliki license
kompetensi untuk menangani
kondisi darurat (seperti fire fighter,
first aider, dll)?
10.5 Does your company provide Please evidence and list of emergency
R
emergency response facilities (eg.,
fire extinguisher, first aid box,
□ facilities
Lampirkan buktinya dan daftar fasilitas EPR
medical bag, evacuation route,
etc)?
Apakah perusahaan anda memiliki
fasilitas EPR (seperti APAR, kotak
P3K, tas bagmed, peta rute

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MANAGEMENT SYSTEM
Subcontractor HSE Pre-Qualification Questionnaire
Revision : 00 Effective date: 20-05-2019

evakuasi, dll)?
11. INCIDENT REPORTING, INVESTIGATION & STATISTICAL DATA
11.1 Does your company have a written Please provide copy
□
procedure to report, investigate and
record incidents?
R
Lampirkan salinannya

Apakah perusahaan anda memiliki

prosedur tertulis yang mengatur
pelaporan, investigasi dan rekaman
kasus insiden ?
11.2 Do you record the incidents Please provide summary of incident occurred
(accident and near miss)?
Apakah perusahaan anda merekam
□ R
within last 3 year
Lampirkan rekaman kasus insiden yang
kasus insiden (kecelakaan dan pernah terjadi selama 3 tahun terakhir
hampir celaka)?
11.3 Is there any documented incident Please explain and provide copy
communication flowchart?
Apakah ada flowchart komunikasi /
□ R
Jelaskan dan lampirkan salinannya

pelaporan insiden yang

terdokumentasi ?
11.4 Do you record the HSE Please provide evidence
performance containing the □
frequency rate & severity rate and
R
Lampirkan salinannya

document safe man-hours?

Apakah perusahaan anda merekam
kinerja K3L yang memuat FR
(frequency rate) & severity rate
(SR) dan mendokumentasikan jam
kerja aman ?
11.5 Does your company have a process Please explain and provide evidence
to share lessons learned on
incidents and near miss?
□ R
Jelaskan dan lampirkan buktinya

Apakah perusahaan anda memiliki

proses untuk berbagi informasi
tentang pelajaran yang didapat dari
insiden dan kejadian hampir celaka?
12. INSPECTION AND AUDIT
12.1 Does your company have a written Please provide copy
HSE audit procedure?
Apakah perusahaan anda memiliki
□ R
Lampirkan salinanya

prosedur audit K3L?

12.2 Is there any documented Please provide evidence
inspection / audit program?
Apakah ada program audit /
□ R
Lampirkan buktinya

inspeksi yang terdokumentasi?

12.3 Do you have a process in place to Please explain and provide evidence
track recommendation and
corrective action to completion
□ R
Jelaskan dan lampirkan buktinya

within the assigned time?

Apakah perusahaan anda
mempunyai proses untuk melacak
pelaksanaan rekomendasi audit /
inspeksi dan langkah perbaikan
dalam waktu yang telah
ditentukan ?

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HEALTH, SAFETY, ENVIRONMENT

MANAGEMENT SYSTEM
Subcontractor HSE Pre-Qualification Questionnaire
Revision : 00 Effective date: 20-05-2019

13. MANAGEMENT MEETING

13.1 Does your company hold periodic Please explain and provide evidence (eg.,
management review meeting to
review your HSE management
□ R minutes of meeting)
Jelaskan dan lampirkan salinanya (seperti
system? minutes meeting)
Apakah perusahaan anda
mengadakan meeting tinjauan
manajemen secara berkala untuk
meninjau sistem manajemen K3L ?
Total Checklist Item 57
TOTAL COMPLIANCE
PERCENTAGE

Compliance Percentage/ Persentase Pemenuhan

 Level 1: Pencapaian 1 – 40 % (Buruk/ Poor)

 Level 2: Pencapaian 41 – 65 % (Sedang/ Average)
 Level 3: Pencapaian 66 – 80 % (Baik/ Good)
 Level 4: Pencapaian 81 – 100 % (Sempurna/ Excellent)

Qualification Status of Subcontractor :

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