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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: ...............................................................................


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 : ...................................