CHECKLIST KESELAMA BULAN/TAHUN NAMA PETUGAS NO
KATEGORI
1
Elektrikal
"
Ke#erian
&
En$ineerin$
)
Reik' 6at! / Ter%eleet Ter%eleet
: : NO
MASALAH
1 " & ) + 0 3 5 1 " & ) + 0 3 5 9 1 1 " & ) + 0
Panel anel lit litri rik k R! R!ak ak Ka#el a#el Men$ Men$el el!% !%a a L'ka L'kai i %ene %ene(%a (%atan tan K!ran$ !ran$ O%ti O%ti(a (all Ka#el Ka#el *an *an St'% k'ntra k'ntrak k #er*ek #er*ekatan atan *en$an *en$an !(#er !(#er air Panel Panel Litrik Litrik ti*ak ti*ak #er*e #er*ekat katan an *en$an *en$an ,ata,ata-el. el. air ata! ata! #aan #aan ki(ia ki(ia Pela#e Pela#elan lan alatal alatalat at 2an$ ti*ak ti*ak #er-!n$ #er-!n$ii Pera Peralat latan an Lit Litrik rik terer tererti4 ti4ka kai i Pet!n6! Pet!n6!k k Tekni ekni Tera*a era*a% % %eral %eralatan atan Area K't'r Pint! int! M!*a M!*a *i #!k #!ka Perala Peralatan tan r!(a r!(a tan$$a tan$$a %erl! %erl! *i#erik *i#erikan an : K!lka. K!lka. Mikr' Mikr',a7e ,a7e Tr'li r'li #er #er-!n -!n$i $i *en$a *en$an n #aik #aik Pene( Pene(%at %atan an #ara #aran$ n$ ti*ak ti*ak e!a e!aii Pen2i en2i(% (%an anan an #aa #aan n Ki( Ki(ia ia Pen2i Pen2i(%a (%ana nan n Di Di R!a R!an$ n$ Di% Di%' 'al al R!an$ !an$ 8an 8anit it'r 'r Tert! ert!t! t!% % ke#er e#eri ia an n r!an$ r!an$ *i% *i%' 'al al K'n*i 'n*iii ta# ta#!n$ !n$ $a LPG R!an$ !an$ Panel Panel ti*ak ti*ak terk! terk!n; n;ii Pe(#e e(#er ri ian an e<' e<'! !e e -an -an k'n*i 'n*ii i ,at ,ataa-el el Din*in$ Din*in$ retak retak %a*a %a*a lanta lantai. i. *in*in$. *in*in$. lan$i lan$itla tlan$it. n$it. *an *an ka;a ka;a K'n*ii Pi Pint! K'n*ii *ii Pla-' la-'n n
3 5 9 1 1 " &
K'n* 'n*ii ii #r #riket iket Kek!a ek!ata tan n #ra #rake kett an an* * r! r! =!rnit !rnit!r !r 2an$ 2an$ %erl %erl! ! *i%e *i%er#a r#aiki iki Pen;a Pen;aa2 a2aan aan ti*ak ti*ak '%ti '%ti(a (all Ka#e Ka#ell 2an$ 2an$ #era #erant ntak akan an Pen2i(% Pen2i(%anan anan %eralatan %eralatan ti*ak ti*ak %a*a %a*a te(%atn2 te(%atn2a a lantai li;in
HASIL OBSERVASI OBSERVASI YA YA TIDAK
)
Reik' 6at! / Ter%eleet Ter%eleet
3 5 9 1 1 " &
K'n* 'n*ii ii #r #riket iket Kek!a ek!ata tan n #ra #rake kett an an* * r! r! =!rnit !rnit!r !r 2an$ 2an$ %erl %erl! ! *i%e *i%er#a r#aiki iki Pen;a Pen;aa2 a2aan aan ti*ak ti*ak '%ti '%ti(a (all Ka#e Ka#ell 2an$ 2an$ #era #erant ntak akan an Pen2i(% Pen2i(%anan anan %eralatan %eralatan ti*ak ti*ak %a*a %a*a te(%atn2 te(%atn2a a lantai li;in
AN LOKASI
PI>
KET
TINDAK TINDAK LAN8UT
)
Reik' 6at! / Ter%eleet Ter%eleet
3 5 9 1 1 " &
K'n* 'n*ii ii #r #riket iket Kek!a ek!ata tan n #ra #rake kett an an* * r! r! =!rnit !rnit!r !r 2an$ 2an$ %erl %erl! ! *i%e *i%er#a r#aiki iki Pen;a Pen;aa2 a2aan aan ti*ak ti*ak '%ti '%ti(a (all Ka#e Ka#ell 2an$ 2an$ #era #erant ntak akan an Pen2i(% Pen2i(%anan anan %eralatan %eralatan ti*ak ti*ak %a*a %a*a te(%atn2 te(%atn2a a lantai li;in
AN LOKASI
PI>
KET
TINDAK TINDAK LAN8UT
AN LOKASI
PI>
KET
TINDAK TINDAK LAN8UT
ANALISA RESIKO KEAMANAN RSIA HERMINA PASTE Lokasi
Deskripsi Lokasi
$) &) -) /)
Nilai
Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1
Fasilitas Lokasi
M!'la R? Panel R? Oki$en T'ilet U(!( R? T!n$$! A%'tik A%'tik Kair R? A*(? Ra,at Ina% NS P'liklinik R? Men2!!i In-'r(ai R? O%erat'r R? La#'rat!ri!( R? Ra*i'l'$i R? P'li Gi$i R? P'li O#$2n Reka( Me*i R? D'kter R? IGD
N*A Ren+a, Se+an. Tin..i
Peralatan Keaanan $) &) -) /)
N*A Ren+a, Se+an. Tin..i
Probabilitas $) &) -) /)
N*A Ren+a, Se+an. Tin..i
(EDUN( RSIA HERMINA PASTEUR LANTAI & 1 1 1 & 1 1 1 1 1 1 1 1 1 1 1 & & " " " " " 1 1 " 1 1 1 1 1 1 1 1 1 1 1 & & " " " " " " " " " " 1 1 1 1 1 1 1 1 "
Dapak Pela"anan $) &) -) /)
Total
N*A Ren+a, Se+an. Tin..i
1 1 1 " 1 " " 1 1 1 1 1 1 1 1 1 1 1 "
An!aan Relati# $%&$$'
) 0 ) + ) 1 5 + + ) ) ) 9 3 3 3 ) ) 0
1 1?+ 1 1?"+ 1 "?+ " 1?"+ 1?"+ 1 1 1 "?"+ 1?3+ 1?3+ 1?3+ 1 1 1?+
ANALISA RESIKO KEAMANAN RSIA HERMINA PASTE Lokasi
Deskripsi Lokasi
Fasilitas Lokasi $) &) -) /)
Nilai
Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1 Lantai 1
M!'la R? Panel R? Oki$en T'ilet U(!( R? T!n$$! A%'tik A%'tik Kair R? A*(? Ra,at Ina% NS P'liklinik R? Men2!!i In-'r(ai R? O%erat'r R? La#'rat!ri!( R? Ra*i'l'$i R? P'li Gi$i R? P'li O#$2n Reka( Me*i R? D'kter R? IGD
N*A Ren+a, Se+an. Tin..i
Peralatan Keaanan $) &) -) /)
N*A Ren+a, Se+an. Tin..i
Probabilitas $) &) -) /)
N*A Ren+a, Se+an. Tin..i
(EDUN( RSIA HERMINA PASTEUR LANTAI & 1 1 1 & 1 1 1 1 1 1 1 1 1 1 1 & & " " " " " 1 1 " 1 1 1 1 1 1 1 1 1 1 1 & & " " " " " " " " " " 1 1 1 1 1 1 1 1 "
Dapak Pela"anan $) &) -) /)
Total
N*A Ren+a, Se+an. Tin..i
1 1 1 " 1 " " 1 1 1 1 1 1 1 1 1 1 1 "
An!aan Relati# $%&$$'
) 0 ) + ) 1 5 + + ) ) ) 9 3 3 3 ) ) 0
1 1?+ 1 1?"+ 1 "?+ " 1?"+ 1?"+ 1 1 1 "?"+ 1?3+ 1?3+ 1?3+ 1 1 1?+
ANALISA RESIKO KEAMANAN RSIA HERMINA PASTE Lokasi
Lantai Lantai Lantai Lantai Lantai Lantai Lantai Lantai
" " " " " " " "
Deskripsi Lokasi
R? KBBL R? VK R? OK R? >SSU R? Men2!!i R? Panel T'ilet U(!( R? Pera,atan Inteni-
Fas ilit as Lokasi
Per alat an Keaanan
Probabilitas
(EDUN( RSIA HERMINA PASTEUR LANTAI " " " " " " 1 1 1 1 1 1 1 1 1 & " 1 1 1 1 " " "
Dapak Pela"anan
Total
An!aan Relati#
& & 1 1 1 1 1 "
9 9 ) ) ) 3 ) 5
"?"+ "?"+ 1 1 1 1?3+ 1 "
ANALISA RESIKO KEAMANAN RSIA HERMINA PASTE
ANALISA RESIKO KEAMANAN RSIA HERMINA PASTE Lokasi
Lantai Lantai Lantai Lantai Lantai Lantai Lantai Lantai
" " " " " " " "
Deskripsi Lokasi
R? KBBL R? VK R? OK R? >SSU R? Men2!!i R? Panel T'ilet U(!( R? Pera,atan Inteni-
Fas ilit as Lokasi
Per alat an Keaanan
Probabilitas
(EDUN( RSIA HERMINA PASTEUR LANTAI " " " " " " 1 1 1 1 1 1 1 1 1 & " 1 1 1 1 " " "
Dapak Pela"anan
Total
An!aan Relati#
& & 1 1 1 1 1 "
9 9 ) ) ) 3 ) 5
"?"+ "?"+ 1 1 1 1?3+ 1 "
ANALISA RESIKO KEAMANAN RSIA HERMINA PASTE Lokasi
Lantai & Lantai & Lantai & Lantai & Lantai & Lantai &
Deskripsi Lokasi
R? NS R? S%''l'ek R? Pera,atan VIP R? Pera,atan Kela R? S!ite R''( @ SVIP R? G!*an$
Fasilitas Lokasi
Peralatan Keaanan
Probabilitas
(EDUN( RSIA HERMINA PASTEUR LANTAI / 1 1 1 1 1 1 1 1 1 1 1 1 " & " 1 1 1
Dapak Pela"anan
Total
An!aan Relati#
1 1 1 1 1 1
) ) ) ) 5 )
1 1 1 1 " 1
ANALISA RESIKO KEAMANAN RSIA HERMINA PASTE
ANALISA RESIKO KEAMANAN RSIA HERMINA PASTE Lokasi
Lantai & Lantai & Lantai & Lantai & Lantai & Lantai &
Deskripsi Lokasi
R? NS R? S%''l'ek R? Pera,atan VIP R? Pera,atan Kela R? S!ite R''( @ SVIP R? G!*an$
Fasilitas Lokasi
Peralatan Keaanan
Probabilitas
(EDUN( RSIA HERMINA PASTEUR LANTAI / 1 1 1 1 1 1 1 1 1 1 1 1 " & " 1 1 1
Dapak Pela"anan
Total
An!aan Relati#
1 1 1 1 1 1
) ) ) ) 5 )
1 1 1 1 " 1
ANALISA RESIKO KEAMANAN RSIA HERMINA PASTE Lokasi
Lantai Lantai Lantai Lantai Lantai Lantai Lantai Lantai Lantai
) ) ) ) ) ) ) ) )
Deskripsi Lokasi
R? Direkt!r R? Pera,atan VIP R? Pera,atan Kela R? NS R? Panel R? Kant'r T'ilet U(!( R? S%''l'ek R? L'ker Kar2a,an
Fasilitas Lokasi
Peralatan Probabilitas Keaanan
(EDUN( RSIA HERMINA PASTEUR LANTAI 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 & 1 1 1 1 1 1 1 1 1 1 1
Dapak Pela"anan
Total
An!aan Relati#
1 1 1 1 1 1 1 1 1
) ) ) ) ) 0 ) ) )
1 1 1 1 1 1?+ 1 1 1
ANALISA RESIKO KEAMANAN RSIA HERMINA PASTE Lokasi
Lantai Lantai Lantai Lantai Lantai Lantai Lantai Lantai Lantai
Deskripsi Lokasi
) ) ) ) ) ) ) ) )
R? Direkt!r R? Pera,atan VIP R? Pera,atan Kela R? NS R? Panel R? Kant'r T'ilet U(!( R? S%''l'ek R? L'ker Kar2a,an
Fasilitas Lokasi
Peralatan Probabilitas Keaanan
Dapak Pela"anan
Total
An!aan Relati#
1 1 1 1 1 1 1 1 1
) ) ) ) ) 0 ) ) )
1 1 1 1 1 1?+ 1 1 1
(EDUN( RSIA HERMINA PASTEUR LANTAI 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 & 1 1 1 1 1 1 1 1 1 1 1
ANALISA RESIKO KEAMANAN RS1 HERMINA DE Lokasi
GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1
Deskripsi Lokasi
L'##2 Uta(a P' Se;!rit2 R? In-'r(ai IGD Kair R? A*(initrai R? Teknik Klinik Ekek!ti- K'%erai G!*an$ K'%erai M!'la T'ilet U(!( R? Panel Ka(ar 8enaa R? Ga Me*i ATM Gr'!n* Tank Bak I%al Ara(a P!tri TPS B& R? Genet R? Panel PLN TPS N'n B&
Fasilitas Lokasi
Peralatan Probabilitas Keaanan
(EDUN( RA2AT INAP 3 (RI 4 LANTAI & 1 1 & 1 1 1 " " " " 1 1 1 1 1 1 " " 1 1 1 1 1 1 & 1 & " ) " 1 1 ) " ) " 1 1 ) " 1 " 1 1 1 "
1 1 1 " " 1 1 1 " 1 " 1 1 1 " & " " 1 " " 1 1
Dapak Pela"anan
Total
1 1 1 " " 1 1 1 " 1 1 1 1 1 ) 1 ) ) 1 & " " "
) 0 ) 5 5 ) ) ) 5 ) + ) 0 3 1" 0 1" 1" ) 11 3 + 0
ANALISA RESIKO KEAMANAN RS1 HERMINA DE Lokasi
GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1 GRI 1
Deskripsi Lokasi
L'##2 Uta(a P' Se;!rit2 R? In-'r(ai IGD Kair R? A*(initrai R? Teknik Klinik Ekek!ti- K'%erai G!*an$ K'%erai M!'la T'ilet U(!( R? Panel Ka(ar 8enaa R? Ga Me*i ATM Gr'!n* Tank Bak I%al Ara(a P!tri TPS B& R? Genet R? Panel PLN TPS N'n B&
Fasilitas Lokasi
Peralatan Probabilitas Keaanan
(EDUN( RA2AT INAP 3 (RI 4 LANTAI & 1 1 & 1 1 1 " " " " 1 1 1 1 1 1 " " 1 1 1 1 1 1 & 1 & " ) " 1 1 ) " ) " 1 1 ) " 1 " 1 1 1 "
1 1 1 " " 1 1 1 " 1 " 1 1 1 " & " " 1 " " 1 1
Dapak Pela"anan
Total
1 1 1 " " 1 1 1 " 1 1 1 1 1 ) 1 ) ) 1 & " " "
) 0 ) 5 5 ) ) ) 5 ) + ) 0 3 1" 0 1" 1" ) 11 3 + 0
ANALISA RESIKO KEAMANAN RS1 HERMINA DE Lokasi
GRI " GRI " GRI " GRI " GRI " GRI " GRI "
Deskripsi Lokasi
R? VIP *an S!ite R''( VK OK R? Panel NS In-'r(ai R? O%erat'r
Fasilitas Lokasi
Peralatan Probabilitas Keaanan
(EDUN( RA2AT INAP 3 (RI 4 LANTAI & 1 ) ) ) ) & 1 1 1 1 1 1 1
1 " " 1 1 1 1
Dapak Pela"anan
Total
1 " " 1 1 1 1
0 1" 1" 0 ) ) )
ANALISA RESIKO KEAMANAN RS1 HERMINA DE Lokasi
GRI " GRI " GRI " GRI " GRI " GRI " GRI "
Deskripsi Lokasi
R? VIP *an S!ite R''( VK OK R? Panel NS In-'r(ai R? O%erat'r
Fasilitas Lokasi
Peralatan Probabilitas Keaanan
(EDUN( RA2AT INAP 3 (RI 4 LANTAI & 1 ) ) ) ) & 1 1 1 1 1 1 1
1 " " 1 1 1 1
Dapak Pela"anan
Total
1 " " 1 1 1 1
0 1" 1" 0 ) ) )
ANALISA RESIKO KEAMANAN RS1 HERMINA DE Lokasi
GRI & GRI & GRI & GRI & GRI & GRI & GRI & GRI & GRI & GRI & GRI & GRI & GRI &
Deskripsi Lokasi
R? Ba2i R? H>U R? I>U R? PI>U R? NI>U R? I'lai R? OBSGYN Kl? 1.".& R? VIP *an S!ite R''( R? =erina In-eki R? =erina N'n In-eki R? Alat Linen NS
R? T!n$$!
Fasilitas Lokasi
Peralatan Probabilitas Keaanan
(EDUN( RA2AT INAP 3 (RI 4 LANTAI / " " ) ) ) ) ) ) ) ) " " & 1 & 1 ) ) 1 1 1 1 1 1 1 1
" " " " " 1 1 1 " " " 1 1
Dapak Pela"anan
Total
& " " " " " 1 1 " " 1 1 1
9 1" 1" 1" 1" 3 0 0 1" 0 + ) )
ANALISA RESIKO KEAMANAN RS1 HERMINA DE Lokasi
GRI & GRI & GRI & GRI & GRI & GRI & GRI & GRI & GRI & GRI & GRI & GRI & GRI &
Deskripsi Lokasi
R? Ba2i R? H>U R? I>U R? PI>U R? NI>U R? I'lai R? OBSGYN Kl? 1.".& R? VIP *an S!ite R''( R? =erina In-eki R? =erina N'n In-eki R? Alat Linen NS
R? T!n$$!
Fasilitas Lokasi
Peralatan Probabilitas Keaanan
(EDUN( RA2AT INAP 3 (RI 4 LANTAI / " " ) ) ) ) ) ) ) ) " " & 1 & 1 ) ) 1 1 1 1 1 1 1 1
" " " " " 1 1 1 " " " 1 1
Dapak Pela"anan
Total
& " " " " " 1 1 " " 1 1 1
9 1" 1" 1" 1" 3 0 0 1" 0 + ) )
ANALISA RESIKO KEAMANAN RS1 HERMINA DE Lokasi
GRI ) GRI ) GRI ) GRI ) GRI ) GRI ) GRI )
Deskripsi Lokasi
NS Anak
R? Linen R? I'lai R? Kl 1.".& Anak R? VIP *an S!ite R''( Anak R? Panel Pla2$r'!n*
Fasilitas Lokasi
Peralatan Probabilitas Keaanan
(EDUN( RA2AT INAP 3 (RI 4 LANTAI 0 1 1 " 1 1 " " " " " & " 1 1
1 1 " " " 1 1
Dapak Pela"anan
Total
1 " 1 & & 1 1
) 0 0 9 9 3 )
ANALISA RESIKO KEAMANAN RS1 HERMINA DE Lokasi
GRI ) GRI ) GRI ) GRI ) GRI ) GRI ) GRI )
Deskripsi Lokasi
NS Anak
R? Linen R? I'lai R? Kl 1.".& Anak R? VIP *an S!ite R''( Anak R? Panel Pla2$r'!n*
Fasilitas Lokasi
Peralatan Probabilitas Keaanan
(EDUN( RA2AT INAP 3 (RI 4 LANTAI 0 1 1 " 1 1 " " " " " & " 1 1
1 1 " " " 1 1
Dapak Pela"anan
Total
1 " 1 & & 1 1
) 0 0 9 9 3 )
ANALISA RESIKO KEAMANAN RS1 HERMINA DE Lokasi
GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI +
Deskripsi Lokasi
R? Marketin$ R? Tata B'$a R? Linen *an La!n*r2 G!*an$ Baa G!*an$ Kerin$ G!*an$ U(!( R? Ga El%i6i R? Sekretariat R? Direki R? Per'nalia T'ilet U(!( R? R!($a
R? Ke!an$an R? Alke R? Diklat R? R? R? R? R
Ra%at EDP Panel Ara(a Pria ISS
Fasilitas Lokasi
Peralatan Probabilitas Keaanan
(EDUN( RA2AT INAP 3 (RI 4 LANTAI 5 1 1 " & " & " " " " & 1 ) " 1 1 1 1 1 " 1 1 1 1 1 1 1 1 1 1 1 1 1 1 & 1 1 1 1 1
1 " " 1 1 1 " 1 1 " 1 1 1 1 1 1 1 1 1 1
Dapak Pela"anan
Total
1 " " 1 1 1 ) 1 1 1 1 1 1 1 1 1 1 1 1 1
) 9 9 0 0 0 1" ) ) 0 ) ) ) ) ) ) ) 0 ) )
ANALISA RESIKO KEAMANAN RS1 HERMINA DE Lokasi
GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI + GRI +
Deskripsi Lokasi
R? Marketin$ R? Tata B'$a R? Linen *an La!n*r2 G!*an$ Baa G!*an$ Kerin$ G!*an$ U(!( R? Ga El%i6i R? Sekretariat R? Direki R? Per'nalia T'ilet U(!( R? R!($a
R? Ke!an$an R? Alke R? Diklat R? Ra%at R? EDP R? Panel R? Ara(a Pria R? ISS R? L'ker anita Per%!takaan R? K'(ite Me*ik
Fasilitas Lokasi
Peralatan Probabilitas Keaanan
(EDUN( RA2AT INAP 3 (RI 4 LANTAI 5 1 1 " & " & " " " " & 1 ) " 1 1 1 1 1 " 1 1 1 1 1 1 1 1 1 1 1 1 1 1 & 1 1 1 1 1 1 1 1 1 1 1
1 " " 1 1 1 " 1 1 " 1 1 1 1 1 1 1 1 1 1 1 1 1
Dapak Pela"anan
Total
1 " " 1 1 1 ) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
) 9 9 0 0 0 1" ) ) 0 ) ) ) ) ) ) ) 0 ) ) ) ) )
ANALISA RESIKO KEAMANAN RS1 HERMINA DE Lokasi
GRI GRI GRI GRI
0 0 0 0
Deskripsi Lokasi
R? R? R? R?
G!*an$ Ari% Li-t Panel 8anit'r
Fasilitas Lokasi
Peralatan Probabilitas Keaanan
(EDUN( RA2AT INAP 3 (RI 4 LANTAI 6 & & " " & 1 1 1
1 & 1 1
Dapak Pela"anan
Total
1 " 1 1
5 9 0 )
ANALISA RESIKO KEAMANAN RS1 HERMINA DE Lokasi
GRI GRI GRI GRI
0 0 0 0
Deskripsi Lokasi
R? R? R? R?
G!*an$ Ari% Li-t Panel 8anit'r
Fasilitas Lokasi
Peralatan Probabilitas Keaanan
(EDUN( RA2AT INAP 3 (RI 4 LANTAI 6 & & " " & 1 1 1
POK An!aan Relati#
1 1?+ 1 " " 1 1 1 " 1 1?"+ 1 1?+ 1?3+ & 1?+ & & 1
1 & 1 1
Dapak Pela"anan
Total
1 " 1 1
5 9 0 )
POK An!aan Relati#
1 1?+ 1 " " 1 1 1 " 1 1?"+ 1 1?+ 1?3+ & 1?+ & & 1 "?3+ 1?3+ 1?"+ 1?+
POK An!aan Relati#
1?+ & & 1?+ 1 1 1
POK An!aan Relati#
1?+ & & 1?+ 1 1 1
POK An!aan Relati#
"?"+ & & & & 1?3+ 1?+ 1?+ & 1?+ 1?"+ 1 1
POK An!aan Relati#
"?"+ & & & & 1?3+ 1?+ 1?+ & 1?+ 1?"+ 1 1
POK An!aan Relati#
1 1?+ 1?+ "?"+ "?"+ 1?3+ 1
POK An!aan Relati#
1 1?+ 1?+ "?"+ "?"+ 1?3+ 1
POK An!aan Relati#
1 "?"+ "?"+ 1?+ 1?+ 1?+ & 1 1 1?+ 1 1 1 1 1 1 1 1?+ 1 1
POK An!aan Relati#
1 "?"+ "?"+ 1?+ 1?+ 1?+ & 1 1 1?+ 1 1 1 1 1 1 1 1?+ 1 1 1 1 1
POK An!aan Relati#
" "?"+ 1?+ 1
POK An!aan Relati#
" "?"+ 1?+ 1
CHECKLIST KEAMANAN BULAN/TAHUN NAMA PETUGAS
NO
1
KATEGORI
Kea(anan
: :
NO
MASALAH
1 " & ) +
Kar2a,an ti*ak (en$$!nakan tan*a Pen$enal Pint! 2an$ k!n;i Site( Kea(anan #er-!n$i #aik Kea(anan %a*a area %!#lik Pe(aa(an taC tera*a% %r'e*!r keela(atan
0 3
%e(aa(an taC tera*a% tin*akan %en;e$aan %en;!likan #a2i %e(aa(an taC tentan$ k'*e e(er$en;2
HASIL OBSERVASI YA TIDAK
LOKASI
S!(e* Pet!$a
??F
CHECKLIST KEAMANAN BULAN/TAHUN NAMA PETUGAS
NO
1
KATEGORI
Kea(anan
: :
NO
MASALAH
1 " & ) +
Kar2a,an ti*ak (en$$!nakan tan*a Pen$enal Pint! 2an$ k!n;i Site( Kea(anan #er-!n$i #aik Kea(anan %a*a area %!#lik Pe(aa(an taC tera*a% %r'e*!r keela(atan
0 3
%e(aa(an taC tera*a% tin*akan %en;e$aan %en;!likan #a2i %e(aa(an taC tentan$ k'*e e(er$en;2
HASIL OBSERVASI YA TIDAK
LOKASI
S!(e* Pet!$a
??F
PI>
KET
n$. ??????????????????????????????? Men$eta!i Ke%ala Unit Ker6a
TINDAK LAN8UT
PI>
TINDAK LAN8UT
KET
n$. ??????????????????????????????? Men$eta!i Ke%ala Unit Ker6a
CHECKLIST KESELAMATAN DAN KEAMANAN FASILITAS UNIT KER8A TANGGAL NO
1
"
KATEGORI
Elektrikal
Ke#erian
: : NO
MASALAH
1
Panel litrik a(an
"
Ka#el tertata *en$an #aik
&
L'kai %ene(%atan K!ran$ O%ti(al
)
Ka#el *an St'% k'ntrak #er*ekatan *en$an !(#er air
+
Panel Litrik ti*ak #er*ekatan *en$an ,ata-el. air ata! #aan ki(ia
0
Pela#elan alatalat 2an$ ti*ak #er-!n$i
3
Peralatan Litrik tererti4kai
5
Pet!n6!k Tekni Tera*a% %eralatan
9
Pe(aa(an taC tentan$ %r'e*!r keela(atan %en$$!naan alat (e*i
1
Genet Ber-!n$i *en$an #aik
11
E(er$en;2 la(% #er-!n$i #aik
1
Area K't'r
"
Pint! M!*a *i #!ka
&
Peralatan r!(a tan$$a %erl! *i#erikan : K!lka. Mikr',a7e
)
Tr'li #er-!n$i *en$an #aik
+
Pene(%atan #aran$ ti*ak e!ai
0
Pen2i(%anan #aan Ki(ia
3
R!an$ 8anit'r Tert!t!%
5 1
K'n*ii ta#!n$ $a LPG Tan$$a *ar!rat (!*a ter6an$ka!
"
APAR Alat Pe(a*a( A%i Rin$anF #el!( Ke*al!ara
&
=ire alar( #er-!n$i #aik
)
Panel litrik #er-!n$i #aik
+
Pen2i(%anan #aran$ ti*ak le#i *ari 15 in;i *ari lan$itlan$it
HASIL OBSERVASI YA TIDAK
KET
CHECKLIST KESELAMATAN DAN KEAMANAN FASILITAS : :
UNIT KER8A TANGGAL NO
1
"
KATEGORI
Elektrikal
Ke#erian
NO 1
Panel litrik a(an
"
Ka#el tertata *en$an #aik
&
L'kai %ene(%atan K!ran$ O%ti(al
)
Ka#el *an St'% k'ntrak #er*ekatan *en$an !(#er air
+
Panel Litrik ti*ak #er*ekatan *en$an ,ata-el. air ata! #aan ki(ia
0
Pela#elan alatalat 2an$ ti*ak #er-!n$i
3
Peralatan Litrik tererti4kai
5
Pet!n6!k Tekni Tera*a% %eralatan
9
Pe(aa(an taC tentan$ %r'e*!r keela(atan %en$$!naan alat (e*i
1
Genet Ber-!n$i *en$an #aik
11
E(er$en;2 la(% #er-!n$i #aik
1
Area K't'r
"
Pint! M!*a *i #!ka
&
Peralatan r!(a tan$$a %erl! *i#erikan : K!lka. Mikr',a7e
)
Tr'li #er-!n$i *en$an #aik
+
Pene(%atan #aran$ ti*ak e!ai
0
Pen2i(%anan #aan Ki(ia
3
R!an$ 8anit'r Tert!t!%
5 1
&
)
P'teni Ke#akaran
En$ineerin$
0
3
Reik' 6at!/ter%eleet
APD
Pen$en*alian In-eki
K'n*ii ta#!n$ $a LPG Tan$$a *ar!rat (!*a ter6an$ka!
"
APAR Alat Pe(a*a( A%i Rin$anF #el!( Ke*al!ara
&
=ire alar( #er-!n$i #aik
)
Panel litrik #er-!n$i #aik
+
Pen2i(%anan #aran$ ti*ak le#i *ari 15 in;i *ari lan$itlan$it
0
Baan (!*a ter#akar *i ekitar !(#er %ana
3
K'ri*'r #e#a a(#atan
5
K'n*ii Pe(aan$an APAR 8eni APARF
9
Pen2i(%anan #aran$ *i *aera 2an$ (!*a ter#akar
1
Pen2i(%anan #aran$#aran$ 2an$ (!*a ter#akar (ele#ii t'k
11
Ra(#! keela(atan ti*ak 6ela
1"
K'n*ii tata R!an$
1&
Dite(!kan %!nt!n$ r'k'k
1
R!an$ Panel ti*ak terk!n;i
"
Pe(#erian e<'!e -an
&
k'n*ii ,ata-el
)
Din*in$ retak %a*a lantai. *in*in$. lan$itlan$it. *an ka;a
+
K'n*ii Pint! Beri
0
K'n*ii Pla-'n Beri
3
K'n*ii #riket A(an
5
Kek!atan #raket an* r!# A(an
9
=!rnit!r 2an$ %erl! *i%er#aiki
1
+
MASALAH
Pen;aa2aan ti*ak '%ti(al
1
Ka#el 2an$ #erantakan
"
Pen2i(%anan %eralatan ti*ak %a*a te(%atn2a
&
lantai li;in
1
APD : Hilan$. ti*ak la2ak %akai *an ti*ak *i$!nakan
"
Ra(#! te(%at APD
&
Kee!aian %en$$!naan APD
)
A%aka %ere*iaan APD (en;!k!%i
1
K'n*ii k!lka Terk!n;i
"
S!! k!lka Se!ai
&
Makan *an (in!( *i area ker6a
)
Pelatakan linen #eri. linen k't'r *an linen in-eki! e!ai
+
Pe(iaan a(%a (e*i *an a(%a n'n (e*i
0
Pen!t!% (atra r'#ek
3
K'n*ii li(#a %e(#!an$an 6ar!( Ter#!ka
5
Pe(anta!an !! r!an$an Se!ai
Pe(aanan taC tera*a% %ela%'ran *an %enan$anan tert!!k 6ar!( *an li(#a
HASIL OBSERVASI YA TIDAK
KET
&
)
P'teni Ke#akaran
En$ineerin$
0
Baan (!*a ter#akar *i ekitar !(#er %ana
3
K'ri*'r #e#a a(#atan
5
K'n*ii Pe(aan$an APAR 8eni APARF
9
Pen2i(%anan #aran$ *i *aera 2an$ (!*a ter#akar
1
Pen2i(%anan #aran$#aran$ 2an$ (!*a ter#akar (ele#ii t'k
11
Ra(#! keela(atan ti*ak 6ela
1"
K'n*ii tata R!an$
1&
Dite(!kan %!nt!n$ r'k'k
1
R!an$ Panel ti*ak terk!n;i
"
Pe(#erian e<'!e -an
&
k'n*ii ,ata-el
)
Din*in$ retak %a*a lantai. *in*in$. lan$itlan$it. *an ka;a
+
K'n*ii Pint! Beri
0
K'n*ii Pla-'n Beri
3
K'n*ii #riket A(an
5
Kek!atan #raket an* r!# A(an
9
=!rnit!r 2an$ %erl! *i%er#aiki
1
+
0
3
Reik' 6at!/ter%eleet
APD
Pen$en*alian In-eki
Ka#el 2an$ #erantakan
"
Pen2i(%anan %eralatan ti*ak %a*a te(%atn2a
&
lantai li;in
1
APD : Hilan$. ti*ak la2ak %akai *an ti*ak *i$!nakan
"
Ra(#! te(%at APD
&
Kee!aian %en$$!naan APD
)
A%aka %ere*iaan APD (en;!k!%i
1
K'n*ii k!lka Terk!n;i
"
S!! k!lka Se!ai
&
Makan *an (in!( *i area ker6a
)
Pelatakan linen #eri. linen k't'r *an linen in-eki! e!ai
+
Pe(iaan a(%a (e*i *an a(%a n'n (e*i
0
Pen!t!% (atra r'#ek
3
K'n*ii li(#a %e(#!an$an 6ar!( Ter#!ka
5
Pe(anta!an !! r!an$an Se!ai
9
Pe(aanan taC tera*a% %ela%'ran *an %enan$anan tert!!k 6ar!( *an li(#a (e*i
1
5
9
1
Ke#erian Tan$an
Baan Ber#aa2a
Pela#elan *an Ra(#!
A*a Pelakananaan ;!;i tan$an
"
A*a Ketere*ian ti!. a#!n *an an* r!#
1
A*a Pela#elan #aan ki(ia
"
Pen2i(%anan #aan ki(ia *i lantai
&
A*a %en;atatan tan$$al tera*a% #aan ki(ia 2an$ *i #!ka
)
A*a te(%at Pe(#!an$an Li(#a Ber#aa2a
+
A*a Pe(iaan li(#a #er#aa2a
0
Peletakan k'tak li(#a ta6a( Se!ai
3
A*a =rek!eni %en$$antian
1
Pela#elan/ra(#! 2an$ ilan$. ti*ak e!ai *an l'n$$$ar
"
Ra(#! keela(atan ilan$/ti*ak 6ela
&
Pela#elan tera*a% #aan 2an$ (!*a ter#akar
)
Ra(#! e7ak!ai ti*ak 6ela
+
A*a Ra(#! ;!;i tan$an
0
Pe(aa(an taC tera*a% 6al!r e7ak!ai *an l'kai *an ;ara %en$$!naan APAR Kar2a,an ti*ak (en$$!nakan tan*a Pen$enal
"
Kea(anan
Site( Kea(anan #er-!n$i #aik
)
Kea(anan %a*a area %!#lik
+
A*a Pe(aa(an taC tera*a% %r'e*!r keela(atan
0
A*a Pe(aa(an taC tera*a% tin*akan %en;e$aan %en;!likan #a2i A*a Pe(aa(an taC tentan$ k'*e e(er$en;2
1 "
1"
& )
1&
M!*a Ter#akar
Ter*a%at Pint!Pint! 2an$ k!n;i
&
3
K'ntr!ki Ban$!nan
Pe(aa(an taC tera*a% %enan$anan li(#a (e*i/#er#aa2a
1
1
11
Pen;aa2aan ti*ak '%ti(al
1
Ter*a%at Laran$an (er'k'k %a*a e(!a area r!(a akit K'n*ii alat %e(a*a( ke#akaran Ber-!n$i #aik Ter*a%at Pelatian %e(a*a( ke#akaran Ter*a%at Orientai keela(atan tera*a% tena$a ker6a 2an$ (elakanakan %e(#an$!nan
+
Ka#el terkel!%a
1
Baan #er#aa2a *i%iakan #er*aarkan i-atn2a
"
A*a Penan$anan tera*a% t!(%aan #aan 2an$ (!*a ter#akar
Ter*a%at S!(#er air 2an$ (!*a ter6an$ka! a%a#ila ter6a*i %a6ananan at 2an$
9 1
5
9
1
Ke#erian Tan$an
Baan Ber#aa2a
Pela#elan *an Ra(#!
A*a Pelakananaan ;!;i tan$an
"
A*a Ketere*ian ti!. a#!n *an an* r!#
1
A*a Pela#elan #aan ki(ia
"
Pen2i(%anan #aan ki(ia *i lantai
&
A*a %en;atatan tan$$al tera*a% #aan ki(ia 2an$ *i #!ka
)
A*a te(%at Pe(#!an$an Li(#a Ber#aa2a
+
A*a Pe(iaan li(#a #er#aa2a
0
Peletakan k'tak li(#a ta6a( Se!ai
3
A*a =rek!eni %en$$antian
1
Pela#elan/ra(#! 2an$ ilan$. ti*ak e!ai *an l'n$$$ar
"
Ra(#! keela(atan ilan$/ti*ak 6ela
&
Pela#elan tera*a% #aan 2an$ (!*a ter#akar
)
Ra(#! e7ak!ai ti*ak 6ela
+
A*a Ra(#! ;!;i tan$an
0
Pe(aa(an taC tera*a% 6al!r e7ak!ai *an l'kai *an ;ara %en$$!naan APAR Kar2a,an ti*ak (en$$!nakan tan*a Pen$enal
"
Kea(anan
Site( Kea(anan #er-!n$i #aik
)
Kea(anan %a*a area %!#lik
+
A*a Pe(aa(an taC tera*a% %r'e*!r keela(atan
0
A*a Pe(aa(an taC tera*a% tin*akan %en;e$aan %en;!likan #a2i A*a Pe(aa(an taC tentan$ k'*e e(er$en;2
1 "
1"
& )
1&
1)
Ter*a%at Laran$an (er'k'k %a*a e(!a area r!(a akit K'n*ii alat %e(a*a( ke#akaran Ber-!n$i #aik Ter*a%at Pelatian %e(a*a( ke#akaran Ter*a%at Orientai keela(atan tera*a% tena$a ker6a 2an$ (elakanakan %e(#an$!nan
+
Ka#el terkel!%a
1
Baan #er#aa2a *i%iakan #er*aarkan i-atn2a
"
A*a Penan$anan tera*a% t!(%aan #aan 2an$ (!*a ter#akar
M!*a Ter#akar
Lin$k!n$an
Ter*a%at Pint!Pint! 2an$ k!n;i
&
3
K'ntr!ki Ban$!nan
Pe(aa(an taC tera*a% %enan$anan li(#a (e*i/#er#aa2a
1
1
11
Pe(aanan taC tera*a% %ela%'ran *an %enan$anan tert!!k 6ar!( *an li(#a (e*i
&
Ter*a%at S!(#er air 2an$ (!*a ter6an$ka! a%a#ila ter6a*i %a6ananan at 2an$ (!*a ter#akar
)
Tere*ia APAR Alat Pe(a*a( A%i Rin$anF
1
A*an2a Han*rail *i tan$$a. *an *aera #eriik' 6at! 7'i*. ka(ar (an*iF
"
K'n*ii 7entilai Baik
&
Pen$'ntr'lan en$ineerin$ Ter6a*,al
)
O!tlet litrik 2an$ %erl! *i t!t!% Dilak!kan %en$er6aan
1
1+
Lain lain
" & )
Ban*!n$. ?"?? Men2et!6!i Mana6er R!($a
??F
De*i R!kan*i
1&
1)
M!*a Ter#akar
Lin$k!n$an
&
Ter*a%at S!(#er air 2an$ (!*a ter6an$ka! a%a#ila ter6a*i %a6ananan at 2an$ (!*a ter#akar
)
Tere*ia APAR Alat Pe(a*a( A%i Rin$anF
1
A*an2a Han*rail *i tan$$a. *an *aera #eriik' 6at! 7'i*. ka(ar (an*iF
"
K'n*ii 7entilai Baik
&
Pen$'ntr'lan en$ineerin$ Ter6a*,al
)
O!tlet litrik 2an$ %erl! *i t!t!% Dilak!kan %en$er6aan
1
1+
Lain lain
" & )
Ban*!n$. ?"?? Men2et!6!i Mana6er R!($a
??F
TINDAK LAN8UT
De*i R!kan*i
PARA= USER
TINDAK LAN8UT
PARA= USER
PEN(ONTROLAN O78EK 9ITAL RSIA Hari. T$l/Bln/Tn :
NO I1 1 " & ) + 0 3 5 9 1 11 1" 1& 1) 1+
NAMA O78EK 9ITAL 7ERHU7UN(AN DEN(AN KELISTRIKAN*PLN Gar*! PLN Ki%a An$inF Pint! Panel Litrik lantai 1 $e*!n$ la(a Pint! Panel Litrik lantai " $e*!n$ la(a Pint! Panel Litrik lantai & $e*!n$ la(a Pint! Panel Litrik lantai ) $e*!n$ la(a Pint! Panel Litrik lantai + $e*!n$ la(a Pint! Panel Litrik lantai 0 $e*!n$ la(a Pint! Panel Litrik lantai 1 $e*!n$ #ar! Pint! Panel Litrik lantai " $e*!n$ #ar! Pint! Panel Litrik lantai & $e*!n$ #ar! Pint! Panel Litrik lantai ) $e*!n$ #ar! Pint! Panel Litrik lantai + $e*!n$ #ar! Pint! Panel Litrik lantai 0 $e*!n$ #ar! Mein Genet St'k S'lar
AM KONTROL Akti- Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Akti
PEN(ONTROLAN O78EK 9ITAL RSIA Hari. T$l/Bln/Tn :
NO I1 1 " & ) + 0 3 5 9 1 11 1" 1& 1) 1+ II1 1 " &
NAMA O78EK 9ITAL
) III1 1 "
7ERHU7UN(AN DEN(AN KELISTRIKAN*PLN Gar*! PLN Ki%a An$inF Pint! Panel Litrik lantai 1 $e*!n$ la(a Pint! Panel Litrik lantai " $e*!n$ la(a Pint! Panel Litrik lantai & $e*!n$ la(a Pint! Panel Litrik lantai ) $e*!n$ la(a Pint! Panel Litrik lantai + $e*!n$ la(a Pint! Panel Litrik lantai 0 $e*!n$ la(a Pint! Panel Litrik lantai 1 $e*!n$ #ar! Pint! Panel Litrik lantai " $e*!n$ #ar! Pint! Panel Litrik lantai & $e*!n$ #ar! Pint! Panel Litrik lantai ) $e*!n$ #ar! Pint! Panel Litrik lantai + $e*!n$ #ar! Pint! Panel Litrik lantai 0 $e*!n$ #ar! Mein Genet St'k S'lar 7ERHU7UN(AN DEN(AN AIR PAM Meteran Air PAM Air *i Gr'!n*tank Air *i T'rn lantai 0 Ge*!n$ La(a Air *i T'rn lantai 0 Ge*!n$ Bar! Mein P'(%a Air 7ERHU7UN(AN DEN(AN IPAL Mein P'(%a IPAL K'n*ii Air IPAL
& I91 1 " & ) + 0 3 91 1 "
Aliran Air IPAL 7ERHU7UN(AN DEN(AN (AS St'k O" ta#!n$ ke;il St'k O" ta#!n$ #ear St'k N"O St'k U*ara Tekan St'k >O" St'k Ga LPG lantai + V'l!(e O" Li!it 7ERHU7UN(AN DEN(AN LIFT Li-t De%an Ge*!n$ La(a Li-t Belakan$ Ge*!n$ La(a
AM KONTROL Akti- Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Terk!n;i Akti
G1 Pen! Akti-
Akti- Ba! 8erni Lan;ar Ii
Akti- Akti-
&
Li-t Ge*!n$ Bar!
Akti-
Men$eta!i Mana$er RUMGA
De*i R!kan*i
Ka!r IPSRS
G!n$!n M!a(a* N
ERMINA PASTEUR
KETERAN(AN
Ti*ak Ti*ak Ti*ak Ti*ak Ti*ak Ti*ak Ti*ak Ti*ak Ti*ak Ti*ak Ti*ak Ti*ak Ti*ak Ti*ak
G" K''n$
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Ti*ak Ti*ak Ti*ak Ker! Ti*ak K''n$
Ti*ak Ti*ak
Stan*#a2
Ti*ak
Tenik
ar
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BULAN/TAHUN
NO &
STRUKTUR a? Ti*ak 2an$ #? Str!kt ;? Str!kt Dilak *? Le(a
-
PERI;INAN a? Har! #? Har! ;? Mater k'nt *? Per!# a,al
/
DOKUMEN a? Pere
CHECKLIST PEMERIKSAAN 7ULANAN (EDU RSUD KA7UPATEN SUME :
URAIAN
a*a keretakan %a*a tr!kt!r !ta(a. keretakan ke;il ata! retak ra(#!t ar! *i%erika 'le Tena$a A '(%eten *an *i%er#aiki *il'kai? !r *i#an$!n *en$an #aan taan a%i *an ti*ak #era;!n? !r *i#an$!n *en$an k'(%eteni tekni 2an$ (e(a*ai anakan in%eki *an %en$a,aan #an$!nan e;ara te%at i. rak. %eranti. %eralatan *ian$ker *en$an #enar
*ilen$ka%i et $a(#ar ter%aan$ A #!il* *ra,in$ F e!ai 2an$ *i#an$!n *an elal! tere*ia #ila * *ilen$ka%i Iin Men*irikan Ban$!nan IMB F 2an$ *i%erl!kan *an Serti4kat Laik =!n$i SL= F ial k'ntr!ki *i%erika *en$an teliti 'le tena$a ali (aterial/6a(inan k!alita/ k'ntr'l k!alita ela( !ki e!ai %ei4kai 2an$ *i%er2aratkan? aan #an$!nan *ilak!kan *en$an k'n!ltai 2an$ te%at *en$an tena$a ali *an %enelaaan ata ren an$!nan?
7AN(UNAN*(AM7AR PERENCANAAN !6!an ren;ana %e(#an$!nan. %ei4kai tekni. %erit!n$an tr!kt!ral. *itan*atan$ani *an *iaka