FORMULIR PELAPORAN KEJADIAN

LUKA TERTUSUK JARUM / PAPARAN CAIRAN TUBUH

1. Identitas
Nama :
Unit kerja :
2. Rincian kejadian
1. Tanggal dan waktu insiden
 Tanggal :
 Jam :
2. Insiden :
 Luka tusukan jarum suntik
 Luka iris
 Percikan pada mukosa hidung, mulut, kulit
 Percikan pada mata
3. Kronologis insiden
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4. Tindakan yang dilakukan setelah kejadian
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Penerima laporan Pembuat laporan

Paraf
Paraf

Tanggal & jam Tanggal dan jam

lapor lapor