Employee Safety Performance Evaluation Form Template for Indonesia

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Key Requirements PROMPT example:

Employee Safety Performance Evaluation Form

"I need an Employee Safety Performance Evaluation Form for our chemical manufacturing plant in Jakarta, compliant with Indonesian regulations, with extra emphasis on handling hazardous materials and emergency response protocols, to be implemented by March 2025."

Document background

The Employee Safety Performance Evaluation Form is a crucial document used in Indonesian workplaces to assess and document individual employee compliance with safety regulations and practices. This form is designed in accordance with Indonesian labor laws, particularly Government Regulation No. 50 of 2012 on SMK3 implementation, and serves as both a performance evaluation tool and a legal record of safety compliance. It should be completed periodically (typically quarterly or bi-annually) for each employee, documenting their safety behavior, incident history, training completion, and adherence to safety protocols. The form helps organizations maintain compliance with Indonesian safety regulations while promoting a culture of safety awareness and continuous improvement in workplace safety practices.

Suggested Sections

1. Employee Information: Basic details including employee name, ID number, department, position, and evaluation period

2. Safety Rules Compliance: Assessment of employee's adherence to workplace safety rules, PPE usage, and standard operating procedures

3. Safety Awareness: Evaluation of employee's knowledge of safety procedures, emergency protocols, and hazard identification abilities

4. Incident History: Record of any safety incidents, near-misses, or accidents during the evaluation period

5. Safety Initiative: Assessment of proactive safety behaviors, reporting of hazards, and participation in safety improvements

6. Training Completion: Record of completed safety training programs and certifications during the evaluation period

7. Performance Metrics: Quantitative safety performance indicators and scores

8. Evaluation Summary: Overall assessment and final safety performance rating

9. Action Items: Specific safety-related goals and improvement areas for the next period

10. Signatures: Space for signatures of evaluator, employee, and safety officer

Optional Sections

1. Specific Role Safety Requirements: Additional evaluation criteria for specific job roles with unique safety requirements (e.g., heavy machinery operators, chemical handlers)

2. Safety Committee Participation: Evaluation of employee's involvement in safety committees or as safety representative, if applicable

3. Environmental Compliance: Assessment of adherence to environmental safety procedures, if relevant to the role

4. Remote Work Safety Compliance: Evaluation of safety practices for employees who work remotely or off-site

5. Safety Leadership: Assessment of safety leadership and mentoring of other employees, for supervisory roles

Suggested Schedules

1. Appendix A - Safety Performance Rating Scale: Detailed explanation of the rating system and performance indicators used in the evaluation

2. Appendix B - Incident Report Forms: Copies of any incident reports filed during the evaluation period

3. Appendix C - Training Records: Detailed list of completed safety training programs and certifications

4. Appendix D - Previous Evaluation Summary: Summary of the previous evaluation period's performance for comparison

5. Schedule 1 - Role-Specific Safety Criteria: Detailed safety evaluation criteria specific to different job roles

6. Schedule 2 - Improvement Action Plan Template: Template for documenting specific safety improvement goals and timeline

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Manufacturing

Construction

Mining

Oil and Gas

Chemical Processing

Transportation and Logistics

Healthcare

Agriculture

Forestry

Telecommunications

Utilities

Food Processing

Pharmaceutical

Automotive

Aerospace

Shipping and Maritime

Warehouse and Distribution

Industrial Services

Relevant Teams

Health and Safety

Operations

Production

Maintenance

Quality Assurance

Human Resources

Compliance

Risk Management

Training and Development

Environmental Health

Factory Operations

Field Operations

Laboratory Services

Facilities Management

Relevant Roles

Safety Manager

HSE Coordinator

Plant Manager

Operations Supervisor

Production Manager

Maintenance Supervisor

Quality Control Inspector

Machine Operator

Construction Site Supervisor

Warehouse Manager

Laboratory Technician

Field Engineer

Process Engineer

Chemical Handler

Forklift Operator

Electrical Technician

Manufacturing Supervisor

Environmental Health Officer

Risk Assessment Specialist

Safety Training Coordinator

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