TABEL 1. IDENTIFIKASI IDENTIFIK ASI BAHAYA, BAHAYA, PENILAIAN RISIKO, RISIK O, SKALA PRIORITAS, PRIORITAS, PENGENDALIAN PENGENDAL IAN RISIKO K3, DAN PENANGGUNG PENANGG UNG JAWAB JAWAB
1. NAMA PERUSAHAAN 2. KEGIAT KEGI ATAN AN 3. LOKASI 4. TANGGAL ANGG AL DIB UAT
: : : :
URAIAN PEKERJAAN
PENILAIAN RESIKO
IDENTIFIKASI BAHAYA
SKALA PRIORITAS
NO. MATA PEMBAYARAN
(1)
(2)
KEKERAPAN
KEPARAHAN
TINGKAT RESI&O
( 4)
(5)
( 6)
& !"#"$%$" %#%'
& S" O%'
(3)
( 7)
PENGENDALIAN RISIKO K3
( 8)
PENANGGUNG JAWAB (Nama P!"#a
%$( 9)
DIVISI 1. UMUM 1.2
M!"#"$%$" & M!"#"$%$" A#%' B%''
& T*%+" '%!%,%- K/$%,%- %#%' !%' +%- ,!%- *"0% & L%$-% %#%' !%' +%" !"# %-,/'%- *%'/
& K% K %-' #%%-%- +%- %$"#"'%$-%
& B%%% %,"!%' #/$" %- +"%$"#,%-
-/-%,% APD ,%-' +%-
%$"#"'%$ #%"--% ! & B%%% %,"!%' '*%+" -%-%- %" +%-
,%-' +%-
$,"'%-%; +"!" $'% '%' %," %+% +%- ,!/'/%P3K %+%" %#%'%- -/" $%%'
,/%- -/" $%%'
& P,*%
& P,*%
+-%- ,,/%'%-
%$"#"'%$ -/-*%-
& B%%% %,"!%' %% -%-,/'%- !%%-
& B%-/-%- +%%%
& A#%' P%+% +%- P3K
M%-%*- +% +%- K K$#%%'%- L% L%#/ L" L"-'%$ & P P %#%'%- K$#%%'%- L%#/ L"-'%$
& B%%% ,#%,%%- !%" -/-% *%#%%+% $%%' #%,$%-%%- ,*%%- ,%-% '"+%, %+%-% R%!/ -%#%- -%#%- #%#/ #"-'%$; R%!/ "-%'%-; R%!/ '/-*/,; P%% , +%- #%"-&#%"-
DIVISI 2. DRAINASE 2.1.(1)
,%-' +%-
%+% #<%$"
%- +"/-%,%- '"+%, -/" $%%'
& S" O%' P,*%
+"'%',%-
-/"%- %+% !%-/-%- ,%-' +%-
& B%%% %,"!%' !%%- +%- %#%'%-
& A#%' -",%' $'%-+%
-",%' %- -//-%- %#%'
& B%%% %,"!%' !%-/-%- ,%-' +%-
1.8.(1)
+"%-,/' %/$
& T,-% T,-% %#%' !%' #/,% !%'
# ,"%'%- #%,$%-%%-
& %$"#"'%$ +%- P#%%-%- P-/*"%- (L%!%'"/ P-/*"%-)
"#"," ,%#"%-
G%#"%- /-'/, S#,%- D%"-%$ +%- S%#/%- A"
& K#%,%%- ',-% %#%' %#" (%-,/#; !%#-- +##) %,"!%' *%%, %-'% -%#" '#%#/ +,%'
%!/
-%#%- #%#/ ; *-"$ #%$'", %!/ "-%'%-; (B%" M=B '/-*/,; %% P#%$'",) ,; P%#%'%; & R%!/ #%/ '%; -%#%- *-"$ %%#%'% B'-
& -%#" %/$ $#%#/ %+% *%%, %%+"#%,/,%- %+%
& P,*% & M%-+
B/%
1.
1;2;.
12;;.
B/%
5.
45;.
22;5;.
URAIAN PEKERJAAN
PENILAIAN RESIKO
IDENTIFIKASI BAHAYA
SKALA PRIORITAS
NO. MATA PEMBAYARAN
KEKERAPAN
(1) 2.2.(1)
(2) P%$%-%- B%'/ +-%- M'%
(3) & K#%,%%- ',-% %#%' %#" (%-,/#; !%#-- +##) %,"!%' *%%, %-'% -%#" '#%#/ +,%' %+% $%%' -%#"%- %$%-%-
(4) #%,$%-%%%$%-%!-% %/$ -/-%,%-
KEPARAHAN
TINGKAT RESI&O
(5)
(6)
& P,*% & M%-+
& T*%+" ""'%$" %+% ,/#"'; %'% +%- %/&%/ %,"!%' +!/ $- %- '"$% # %% ,*% %- -*%,%- $- %+% $%%' !/%'%- '%
%'%/ '%, +-%- %-'%"
DIVISI 3. PEKERJAAN TANAH 3.1.(1%)
G%#"%- B"%
%$& K#%,%%- ',-% %#%' %#" (%-,/#; !%#-- +##) %,"!%' *%%, %-'% -%#"
-%#" %/$ & P,*% %+% *%%, %- & M%-+ %%-
'#%#/ +,%' & B%%% %,"!%' #- %#"%- #-$
'%%-,%-
& K#%,%%- %,"!%' %$"-%# %#%' !%'
+"#%,/,%- %+% #%/ -%-%- %-
!%", +" '%' #,%$" %#"%-; '%-$'%$" %//- +" '%' !/%-%-
3.1.(2)
G%#"%- B%'/
& K#%,%%- ',-% %#%' %#" (%-,/#; !%#-- +##) %,"!%' *%%, %-'% -%#"
-%#" %/$ & P,*% %+% *%%, %- & M%-+ %%-
'#%#/ +,%' & T#/,% ,%-% ',-% %%- !%'/ %$"# %#"%& K#%,%%- %,"!%' %$"-%# %#%' !%' !%", +" '%' #,%$" %#"%-; '%-$'%$"
+"#%,/,%- %+% #%/ -%-%- %- %/$ +"#%,/,%%#" +%- '+ %- !-%
%//- +" '%' !/%-%-
3.2.(1!)
T"!/-%- B"%$% +%" %#"%-
& K#%,%%- %,"!%' -%'/%- #%#/ #"-'%$ ,/%- !%", & K#%,%%- %,"!%' %$"-%# %#%' !%' +" #,%$" ,*%%& K#%,%%- %,"!%' '+ -"!/-%%+% *%#%- '%-*%,%-
#"-'%$ %/$
& P,*%
$'%-+%
& M%-+
%#%' !%' %/$ !%' %- -"!/-%- %+% +-%- '+
DIVISI '. STRUKTUR 7.1 (5) %
B'- /'/ $+%- ?3 MP% #%-'%" *!%'%- #%-'%" #%' +/",
& T*%+" ""'%$" %+% ,/#"'; %'% +%- %/&%/ %,"!%' +!/ $- %- '"$% # %% ,*% %- -*%,%- $- +%- !'& B%%% ,#%,%%- %+% %$%-%!,"$'"- %+% '%-% %#"%- #"/'" : ''"% '%-% %#"%-; ''"!/- '%-% %#"%''"% !-+% *%'/ +%- '#$' *%'/
%,%" APD & P,*% ; '%-%-; # %'%/ & M%-+ -%%- +%%/$ -%%- +"-+"-
(7)
PENGENDALIAN RISIKO K3
(8)
PENANGGUNG JAWAB (Nama P!"#a
%$(9)
URAIAN PEKERJAAN
PENILAIAN RESIKO
IDENTIFIKASI BAHAYA
SKALA PRIORITAS
NO. MATA PEMBAYARAN
(1) 7.3 (3)
(2) B%*% T/#%-%- U 32 U#"
(3) &T*%+" %-/%- "$", %,"!%' ,*% '"+%, %,%" %,%"%- ,*% %'%/ #-,%%#%"- -/" $'%-+% & L/,% ',-% !$" '/#%-%- -*, ,#/% +%" #%-'%" %'%/ +"-+"- & T*%+" ,#%,%%- %'%/ '#/,% %+% $%%' #%,/,%- '-%- %'%/ %!",%$"
KEKERAPAN
KEPARAHAN
TINGKAT RESI&O
(4)
(5)
(6)
%,%" APD & P,*% ; '%-%-; # %'%/ & M%-+ -%%- +%$%'/ $$/%" %- -*, , %/$ +"!" '/#%-%- %/$ $/ % !-%#%%-
!$" '/#%-%-
7.9.(1)
P%$%-%- B%'/
& K#%,%%- ',-% %#%' %#" (%-,/#; !%#-- +##) %,"!%' *%%, %-'% -%#" '#%#/ +,%' %+% $%%' -%#"%- %$%-%!%'/ & T*%+" ""'%$" %+% ,/#"'; %'% +%- %/&%/ %,"!%' +!/ $- %- '"$% # %% ,*% %- -*%,%- $- %+% $%%' !/%'%- '%
7.15.(2)
P!-,%%- B'-
& T*%+" %-/%- "$", %,"!%' ,*% '"+%, %,%" %,%"%- ,*% %'%/ #-,%%#%"- -/" $'%-+% & T*%+" ,#%,%%- %'%/ '#/,% %+% $%%' #%,/,%- !-,%%- !'- %,"!%' -/-%%- %#%' '/,%-%- (*%, %; %#/ !$"; $, +##)
-%#" %/$ & P,*% $#%#/ %+% & M%-+ *%%, %%+"#%,/,%- %+% -/-%,%#%/ %,%" APD ; '%-%-; # %'%/ -%%- +% / / -% %,%" APD & P,*% ; '%-%-; # %'%/ & M%-+ -%%- +%$%'/ $$/%"
(7)
PENGENDALIAN RISIKO K3
(8)
PENANGGUNG JAWAB (Nama P!"#a
%$(9)
TABEL 1. IDENTIFIKASI BAHAYA, PENILAIAN RISIKO, PENGENDALIAN RISIKO K3, PROGRAM K3, DAN BIAYA +)#"-a&a- "-!"& "$"a- -a/a0a-
NAMA PERUSAHAAN KEGIATAN
: :
URAIAN PEKERJAAN
NO. MATA
IDENTIFIKASI BAHAYA
PENGENDALIAN RISIKO K3
PROGRAM
BIAYA
SUMBER DAYA
PEMBAYARAN
(R")a*% (1)
(2)
(3)
(4)
(5)
(6)
DIVISI 1. UMUM 1.2
M!"#"$%$" & M!"#"$%$" A#%' B%''
& T*%+" '%!%,%- K/$%,%- %#%' !%' +%- ,!%- *"0% & L%$-% %#%' !%' +%" !"# %-,/'%- *%'/ & T,-% %#%' !%' #/,% !%'
& S" %- !"#"$%$" %#%' !%'
& S" O%'
%/$ %- "#"," ,%#"%- +%& A#%' !%' %- +"%-,/' %/$ +"",%'
& A#%' -",%' $'%-+%
+-%- -",%' %- $'%-+% & P-%-,%'%- -//-%- %#%' !%'
& S" O%' P,*%
-/-%,%- APD & K%-' #%%-%- +%- %$"#"'%$-%
& B%%% %,"!%' #/$" %- +"%$"#,%# ,"%'%- #%,$%-%%& B%%% %,"!%' !%-/-%- ,%-' +%%$"#"'%$ #%"--% ! & B%%% %,"!%' '*%+" -%-%- %" +%-/"%- %+% !%-/-%- ,%-' +%%$"#"'%$ -/-*%-
& B%-/-%- /', ,%-' +%- %$"#"'%$-%
& P,*%
%/$ +"'%',%- $+","%- /% & B%-/-%- ,%-' +%- %$"#"'%$ #%"--%
& P,*%
%/$ +"!/%' +-%- ,,/%'%- $'/,'/%# & B%-/-%- ,%-' +%- %$"#"'%$ #%"--%
& B%-/-%- +%- %%
%/$ +"!/%' %+% #<%$" #!" '"-" +%" +%% $,"'%-%; +"!" %% $'% '%' %,"
& %$"#"'%$ +%- P#%%-%- P-/*"%- (L%!%'"/ P-/*"%-)
& B%%% %,"!%' !%%- +%- %#%'%%- +"/-%,%- '"+%, -/" $%%' & B%%% %,"!%' %% -%-,/'%- !%%,/%- -/" $%%'
1.8.(1)
& H%/$ '$+"% %+% ,!%,%%-
& A#%' P%+% +%- P3K
+%- ,!/'/%- P3K %+%" & B%%- +%- %#%'%- +"/-%,%- %/$ -/" $ %%'
M%-%*- +%- K$#%%'%- L%#/ L"-'%$ & P%#%'%- K$#%%'%- L%#/ L"-'%$
& B%%% ,#%,%%- !%" -/-% *%#%-
& H%/$ '$+"% %!/ -%#%-
%+% $%%' #%,$%-%%- ,*%%- ,%-%
#%#/ #"-'%$; %!/ "-%'%-; %!/
'"+%, %+%-% R%!/ -%#%- #%#/ #"-'%$;
'/-*/,; %% ,; P%#%'%-
R%!/ "-%'%-; R%!/ '/-*/,; P%% , +%- #%"-&#%"-
,/-",%$"; #%/ '%; $%' - +%- #%"-&#%"- %%#%'%- ,$#%%'%#%#/ #"-'%$
& R%!/ -%#%- #%#/ #"-'%$
P#%$'",) & R%!/ -%#%- *-"$
G%#"%- /-'/, S#,%- D%"-%$ +%- S%#/%- A"
& K#%,%%- ',-% %#%' %#" (%-,/#; !%#-- +##) %,"!%' *%%, %-'% -%#" '#%#/ +,%'
2.2.(1)
P%$%-%- B%'/ +-%- M'%
& K#%,%%- ',-% %#%' %#" (%-,/#; !%#-- +##) %,"!%' *%%, %-'% -%#" '#%#/ +,%' %+% $%%' -%#"%- %$%-%-
& >%%, %-'%% -%#" %/$ +"*%% %% $#%#/ %+% *%%, %%-
& R%!/ "-%'%-
1;4;.
& R%!/ '/-*/,
1;4;.
$#%#/ %+% *%%, %%& B"#% -%#"%- +"#%,/,%- %+% %#% %- /,/
& T*%+" ""'%$" %+% ,/#"'; %'% +%- %/&%/
& P,*% %/$ %,%" APD $'" !%*/
%,"!%' +!/ $- %- '"$% # %%
,*%; $%/- '%-%-; # %'%/ '" !%*%
,*% %- -*%,%- $- %+% $%%'
,%% %'% -%%- +%- $%'/ $$/%"
!/%'%- '%
& P,*% & M%-+
& B"#% -%#"%- +"#%,/,%- %+% %#%
& >%%, %-'%% -%#" %/$ +"*%% %%
$'%-+%; !"#% #/ /', -% !%%% %-/%- %/&%/ ,*% %/$ %,%" %#%' -%'/ -%%$%- ($"%') '/'/ /#/' (%$,)
22;5;.
B'-
DIVISI 2. DRAINASE 2.1.(1)
12;;.
*-"$ #%$'", (B%" M=B
& P,*% & M%-+
URAIAN PEKERJAAN
NO. MATA
IDENTIFIKASI BAHAYA
PENGENDALIAN RISIKO K3
PROGRAM
BIAYA
SUMBER DAYA
PEMBAYARAN
(R")a*% (1)
(2)
(3)
(4)
(5)
DIVISI 3. PEKERJAAN TANAH 3.1.(1%)
G%#"%- B"%
%$& K#%,%%- ',-% %#%' %#" (%-,/#; !%#-- +##) %,"!%' *%%, %-'% -%#"
& >%%, %-'%% -%#" %/$ +"*%% %% $#%#/ %+% *%%, %- %%-
& P,*% & M%-+
'#%#/ +,%' & B%%% %,"!%' #- %#"%- #-$
& M!/%' +%- '%%-,%- ,""-%-
& K#%,%%- %,"!%' %$"-%# %#%' !%'
& B"#% -%#"%- +"#%,/,%- %+% %#% %" %/$
$'%!"#
!%", +" '%' #,%$" %#"%-; '%-$'%$"
-/-%,%- #%/ -%-%- %- /,/
%//- +" '%' !/%-%-
3.1.(2)
G%#"%- B%'/
& K#%,%%- ',-% %#%' %#" (%-,/#; !%#-- +##) %,"!%' *%%, %-'% -%#"
& >%%, %-'%% -%#" %/$ +"*%% %% $#%#/ %+% *%%, %- %%-
& P,*% & M%-+
'#%#/ +,%' & T#/,% ,%-% ',-% %%- !%'/ %$"# %#"%& K#%,%%- %,"!%' %$"-%# %#%' !%' !%", +" '%' #,%$" %#"%-; '%-$'%$"
& B"#% -%#"%- +"#%,/,%- %+% %#% %" %/$ -/-%,%- #%/ -%-%- %- /,/ & P-%#"%- %/$ +"#%,/,%- # %- %- %#" +%- '+ %- !-%
%//- +" '%' !/%-%-
3.2.(1!)
T"!/-%- B"%$% +%" %#"%-
& K#%,%%- %,"!%' -%'/%- #%#/ #"-'%$ ,/%- !%", & K#%,%%- %,"!%' %$"-%# %#%' !%' +" #,%$" ,*%%& K#%,%%- %,"!%' '+ -"!/-%%+% *%#%- '%-*%,%-
& P-%'/%- #%#/ #"-'%$ %/$ $$/%" +-%$'%-+%
& P,*% & M%-+
& P-%$"%- %#%' !%' %/$ +"#%,/,%- # %' %#%' !%' %- !-%#%% & P#%,$%-%%- -"!/-%- %+% *%#%- '%-*%,%%/$ +"#%,/,%- +-%- '+ %- !-%
DIVISI '. STRUKTUR 7.1 (5) %
B'- /'/ $+%- ?3 MP% #%-'%" *!%'%- #%-'%" #%' +/",
& T*%+" ""'%$" %+% ,/#"'; %'% +%- %/&%/
& P,*% %/$ %,%" APD $'" !%*/
& P,*%
%,"!%' +!/ $- %- '"$% # %%
,*%; $%/- '%-%-; # %'%/ '" !%*%
& M%-+
,*% %- -*%,%- $- +%- !'& B%%% ,#%,%%- %+% %$%-%-
,%% %'% -%%- +%- $%'/ $$/%" & D"-+"- %#"%- %/$ +"!" -%%- +"-+"- $/,/-%
!,"$'"- %+% '%-% %#"%- #"/'" : ''"% '%-% %#"%-; ''"!/- '%-% %#"%''"% !-+% *%'/ +%- '#$' *%'/
7.3 (3)
B%*% T/#%-%- U 32 U#"
&T*%+" %-/%- "$", %,"!%' ,*% '"+%, %,%" %,%"%- ,*% %'%/ #-,%%#%"- -/" $'%-+% & L/,% ',-% !$" '/#%-%- -*, ,#/% +%" #%-'%" %'%/ +"-+"- & T*%+" ,#%,%%- %'%/ ' #/,% %+% $%%' #%,/,%- '-%- %'%/ %!",%$"
& P,*% %/$ %,%" APD $'" !%*/
& P,*%
,*%; $%/- '%-%-; # %'%/ '" !%*%
& M%-+
,%% %'% -%%- +%- $%'/ $$/%" $'%-+% & B$" '/#%-%- %- -*, , #/% +%" #%-'%" %'%/ +"-+"- %/$ +"!" #"-+/- & P%!",%$" !$" '/#%-%- %/$ +"#%,/,%- # ,*% $/+% !-%#%%- +"!"+%--%
!$" '/#%-%-
7.9.(1)
P%$%-%- B%'/
& K#%,%%- ',-% %#%' %#" (%-,/#; !%#-- +##) %,"!%' *%%, %-'% -%#" '#%#/ +,%' %+% $%%' -%#"%- %$%-%!%'/ & T*%+" ""'%$" %+% ,/#"'; %'% +%- %/&%/
& >%%, %-'%% -%#" %/$ +"*%% %% $#%#/ %+% *%%, %%& B"#% -%#"%- +"#%,/,%- %+% %#% %" %/$ -/-%,%- #%/ -%-% & P,*% %/$ %,%" APD $'" !%*/
%,"!%' +!/ $- %- '"$% # %%
,*%; $%/- '%-%-; # %'%/ '" !%*%
,*% %- -*%,%- $- %+% $%%'
,%% %'% -%%- +%- $%'/ $$/%"
!/%'%- '%
$'%-+%; !"#% #/ /', -% !%%%
& P,*% & M%-+
(6)
URAIAN PEKERJAAN
NO. MATA
IDENTIFIKASI BAHAYA
PENGENDALIAN RISIKO K3
PROGRAM
BIAYA
SUMBER DAYA
PEMBAYARAN
(R")a*% (1) 7.13.(1)
(2) S%-+%%- (R%"#"-)
(3)
(4)
(5)
& T*%+" %-/%- "$", %,"!%' ,*% '"+%,
& P,*% %/$ %,%" APD $'" !%*/
& P,*%
%,%" %,%"%- ,*% %'%/ #-,%%-
,*%; $%/- '%-%-; # %'%/ '" !%*%
& M%-+
#%"- -/" $'%-+%
,%% %'% -%%- +%- $%'/ $$/%" $'%-+%
& T*%+" ,#%,%%- %'%/ '#/,% %+% $%%' #%,/,%- '-%- %'%/ %!",%$"
& P%!",%$" $%-+%%- (%"#"-) %/$ +"#%,/,%- # ,*% $/+% !-%#%%- +"!"+%--%
!$" %"#"- ($%-+%%-)
7.15.(2)
P!-,%%- B'-
& T*%+" %-/%- "$", %,"!%' ,*% '"+%,
& P,*% %/$ %,%" APD $'" !%*/
& P,*%
%,%" %,%"%- ,*% %'%/ #-,%%-
,*%; $%/- '%-%-; # %'%/ '" !%*%
& M%-+
#%"- -/" $'%-+%
,%% %'% -%%- +%- $%'/ $$/%" $'%-+%
& T*%+" ,#%,%%- %'%/ '#/,% %+% $%%' #%,/,%- !-,%%- !'- %,"!%' -/-%%- %#%' '/,%-%- (*%, %; %#/ !$"; $, +##)
Ketentuan Pengisian Tabel 1: 1. Kolom (1), (2) dan (3) diisi oleh PPK di dalam dokumen pengadaan; 2. Kolom (4) sampai dengan (7) diisi oleh Penyedia Jasa pada saat penawaan;
(6)
