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LAPORAN

PENYELIDIKAN KEJADIAN / KECELAKAAN

Jenis Kejadian Kecelakaan kerja Kecelakaan kerja di Kejadian


di lingkungan RS luar lingkungan RS lainnya
Lokasi Kejadian
Sub Divisi / Unit
Tanggal & Jam Kejadian
Nama Korban / Peralatan
Bagian Tubuh Yang Luka
Cidera Yang Tampak Mata
Alat Yang Menyebabkan Luka /
Yang Menyebabkan Kejadian
Kerugian Yang Ditimbulkan Kecil Serius Besar
Kekerapan Dapat Terjadi Sering Kadang - Kadang Jarang
Kronologi Kejadian
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Penyebab Langsung Kejadian dan Tindakan Yang Menyebabkan Kejadian
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Penyebab Dasar / Utama Yang Disebabkan Faktor Manusia dan Peralatan
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Tindakan Yang Perlu Dilaksanakan untuk menghilangkan penyebab diatas
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....................................................................................................................................(Terlampir4)

Pelapor & Saksi : (TTD&Nama) Rekomendasi PK3RS :

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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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