FORMULIR PELAPORAN KEJADIAN KECELAKAAN DAN PAJANAN
I. IDENTITAS NAMA : ......................... UNIT KERJA : .........................
II. RINCIAN KEJADIAN
1. Tanggal dan waktu insiden Tanggal : .............................. Jam : .............................. 2. Insiden Luka tusukan jarum suntik Luka iris Percikan pada mukosa hidung, mulut atau kulit Percikan pada mata Lain-lain : ...................... 3. Kronologi insiden .......................................................................................................................................... .......................................................................................................................................... .......................................................................................................................................... .................................................................................................................................. 4. Tindakan yang dilakuakn setelah kejadian .......................................................................................................................................... ......................................................................................................................................