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FORM Checklist APD

This document is an inspection form for personal protective equipment. It lists various pieces of safety equipment including clothing, earplugs, gloves, jackets, safety shoes, glasses, harnesses, masks, first aid kits, and fire extinguishers. For each item, it records the quantity available and whether the items are in good or damaged condition. The form is signed by an HSE Officer and Supervisor to acknowledge the inspection.

Uploaded by

Yoko Wardhana Sadewa
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451 views1 page

FORM Checklist APD

This document is an inspection form for personal protective equipment. It lists various pieces of safety equipment including clothing, earplugs, gloves, jackets, safety shoes, glasses, harnesses, masks, first aid kits, and fire extinguishers. For each item, it records the quantity available and whether the items are in good or damaged condition. The form is signed by an HSE Officer and Supervisor to acknowledge the inspection.

Uploaded by

Yoko Wardhana Sadewa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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No.

Dok : FORM/007/HSE/2018
INSPEKSI
ALAT PELINDUNG DIRI
Tgl / Jam : Crew :
Lokasi : Inspektor :

KONDISI
No NAMA PERALATAN JUMLAH KETERANGAN
BAIK RUSAK
1. PERORANGAN
a. Cover All / Work Clothes
b. EarPlug
c. Hand Gloves
d. Jacket
e. Rain Coat
f. Safety Helmet
g. Rubber Safety Shoes
h. Safety Shoes
i. Safety Glasses
2. PERALATAN KESELAMATAN
a. Full Body Harness
b. Ear Muff
c. Masker
d. First Aid Kit
e. Multi Gas Detector
f. Safety Goggles
g. Wind Sock

3. PERALATAN KEBAKARAN
a. Fire Extinguisher
Saran :

Inspeksi Oleh Diketahui Oleh

HSE Officer Supervisor / Lead Operation

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