RUMAH SAKIT

INTAN MEDIKA
BLAWI KARANGBINANGUN LAMONGAN

FORM LAPORAN KEJADIAN K3

1. INFORMASI KEJADIAN
a. Jenis Kejadian : Kecelakaan Kerja Kerusakan Fasilitas Kerja
b. Tempat Kejadian : Unit...................................Ruang.........................................
c. Tgl & Jam Kejadian :..............................................................................................
d. Nama pelapor :..............................................................................................
e. Nama Saksi :..............................................................................................
f. Nama Investigator :..............................................................................................

2. URAIAN KEJADIAN :
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3. KEMUNGKINAN RISIKO KEJADIAN

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 RUMAH SAKIT
INTAN MEDIKA
BLAWI KARANGBINANGUN LAMONGAN

4. TINDAKAN YANG DILAKUKAN

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5. REKOMENDASI PENANGGULANGAN KEJADIAN

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Dilaporkan kepada komite K3 RS Intan Medika pada :
Hari:..................................... Tanggal................................. Pukul...................................

Pelapor Penerima Laporan

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Unit :............................... Komite K3 RS Intan Medika