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FORMULIR PELAPORAN KECELAKAAN KERJA

RUMAH SAKIT UMUM PRIMA MEDIKA

Nama : ...........................................................................................................
Umur : ...........................................................................................................
Alamat : ...........................................................................................................
Instalasi/ Unit Kerja : ...........................................................................................................
Status : Karyawan/ Penderita/ Pengunjung *
Tanggal/ Jam Kejadian : ...........................................................................................................
Lokasi Kejadian : ...........................................................................................................
Kronologis Kejadian : ...........................................................................................................
...........................................................................................................
Alat Pelindung : ...........................................................................................................
Cedera yang dialami : ...........................................................................................................
Tindakan : ...........................................................................................................
...........................................................................................................

Denpasar, ............................................
Mengetahui,

Ketua K3-RS, Kepala Unit,

( ) ( )

(*) CORET YANG TIDAK PERLU