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Petugas K3 : (TTD&Nama) .................................................................................................................
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Ketua PK3RS : (TTD&Nama) .................................................................................................................
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Lampiran (1)
Bagaimana Kejadian Dapat Terjadi :
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Lampiran (2)
Penyebab Langsung Kejadian dan Tindakan Yang Menyebabkan Kejadian :
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Lampiran (3)
Penyebab Dasar / Utama Yang Disebabkan Faktor Manusia dan Peralatan :
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Lampiran (3)
Tindakan Yang Perlu Dilaksanakan untuk menghilangkan penyebab diatas :
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