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RUMAH SAKIT CITRA HUSADA

Jl. Teratai No. 22 Jember


Telp. (0331) 486200 Fax. (0331) 427088
Web : rscitrahusada.com Email : rs_citrahusada@yahoo.co.id

Laporan Kejadian Tumpahan dan Paparan


Bahan Berbahaya dan Beracun (B3)

RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAXIMAL 2 x 24 JAM

RINCIAN KEJADIAN

1. Nama yang terkena paparan:


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2. Unit kerja: ....................................................................................................................................

3. Tanggal dan Waktu Insiden


Tanggal : ........................................................................................ Jam ......................................

4. Lokasi : .......................................................................................................................................

5. Jenis Bahan: ...............................................................................................................................

6. Kronologis Kejadian
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7. Tindakan yang dilakukan setelah kejadian:


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Pembuat Laporan : ................................... Penerima Laporan : ...................................


Unit : ................................... Unit : ...................................
Paraf : ................................... Paraf : ...................................
Tgl Lapor : ................................... Tgl terima : ...................................