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FORMULIR KECELAKAAN

DI INSTALASI KAMAR BEDAH

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No. Dokumen

No. Revisi

Halaman
1 dari 1

Tanggal terbit
Ditetapkan Oleh,
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LAPORAN KEGAGALAN OPERASI


I.

IDENTITAS PELAPOR :
Nama
:
Unit Kerja :

II.

KRONOLOGI PERISTIWA :
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III. INVESTIGASI / PENYEBAB


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CATATAN / SARAN
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Yang membuat laporan,

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