PT xxxx yyyyyy zzzzzzzz No.

: EHS/005-FM-001
FORM Revision : 02
PENILAIAN RESIKO Application Date : 01/06/10
RISK ASSESSMENT Page 1 of 1
Working Unit : EHS Secretariat Division Head Department Head H&S Representative
Last Review Date :
Next Review Date :
Revision Status :
Date : Date : Date : Date :
1. Hazard Identification 2. Risk Evaluation 3. Risk Control
Residual Risk
Legal Seve Likelih Risk
ID Possible accident / Additional Risk Seve Likeli Risk
No. Work Station/Process Description of Activity* Aspect Hazard Person-at-risk Existing Risk Control rity ood Rating
No.*** ill health Control rity hood Rating
(Y/N)** (S) (L) (SxL)
(S) (L) (SxL)

* : Please add remarks in the activity with (R) for routine, (NR) for non-routine, and (E) for emergency situation
** : If "Y", please add remarks with the number of legal, refer to OHS identification and evaluation of compliance (PLJ/EHS/006-FM-001)
*** : Fill with working area code and number of hazard. Working area code for ID number refer to Table II. Process Owner Code System in SOP Control of Document page 11
Example : for IPA1, ID number will be 01-1, 01-02, 01-3, etc.