No.
: DR/HSE/XYZ/002
Revisi : 00
DAILY SAFETY REPORT Tgl. Efektif :-
Halaman : 1 of 11)
DATE :
1 WEATHER CONDITION
6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00
Note:
2 HSE PERFORMANCE STATISTIC
MANHOURS PREVIOUS TODAY CUMMULATIVE LOST TIME ACCIDENT
TOTAL MANHOURS
HSE INPUT PREV. TODAY CUMM. TARGET REMARKS
Hazard Observation
HSE Inspection & Audit
Safety Meeting
HSE Orientation / Induction
Management Visit
Safety Traning
ERP Drill
Anomally Record
Job Safety Analysis (JSA)
HSE OUTPUT PREV. TODAY CUMM. TARGET REMARKS
First Aid Injury (FAI)
Lose Time Injury ( LTI )
Medical Treatment Injury (MTI)
Fire Incident (FI)
Property Damage
Environment Incident
Total Recordable Injury
NO. ISSUES ACTION PLAN TARGET DATE ACTION BY
1
2
4
5
3 WORK PERMIT
NO. LOCATION PTW No. TYPE SUPERVISO DESCRIPTION OF WORK ISSUE DATE VALID DATE
R
1
2
3
4
5
6
4 MAN POWER
DESCRIPTION ETI Security
SHIFT I
SHIFT II
TOTAL SHIFT I
TOTAL SHIFT II
TOTAL MAN POWER
Plan Additional MP
5 SAFETY HIGHLIGHT (ACTIVITY)
Reported by, Acknowledged by,
HSE Koordinator