Injury Or IIIness Report

(Filed out by nurse first ald person)

Name: ____________________________________ Security No: ________________________________

Home address: ________________________________________________________________________

Age: _________________________ Sex Male □ Femele □

Shift: _________________________ Clock/Emp. No:____________

Dept: ___________________________________________ Foreman: ____________________________

Is injury or illness related to employment? Yes□ No□

Date ot injury or initial diagnosis: ______________________________ Time of Injury: _______________

Describe the illness or injury in detail and indicate the part of body affected , e.g. amputation of right index joint :
fracture of ribs : lead poisoning : dermatitis of left hand ; etc

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Did employee die? Yes □ No□ did employee return to work ? Yes□ No□

If employee did not return to work , indicate last day worked : __________________________________

Name and addres of physician : ___________________________________________________________

If hospitalized , name and address of hospital: _______________________________________________

Names of witnasses : ___________________________________________________________________

Comment: ____________________________________________________________________________

Signature of employee: _________________________________________________________________

Signature of nurse or first aid person : _____________________________________________________

Date: _____________
 Laporan Cedera Atau Ketidaktepatan

(Diberikan oleh perawat dan orang pertama)

Nama: ____________________________________ Keamanan No: ______________________________

Alamat Rumah: ________________________________________________________________________

Usia : _________________________ Jenis Kelamin Laki-laki □ Perempuan□

Bergeser: ______________________ Jam/emp. No : _________________________________

Dept: ____________________________________________ Mandor: ___________________________

Apakah cedera atau penyakit terkait dengan pekerjaan? Ya□ Tidak□

Tanggal cedera atau diagnosis awal : __________________________ Waktu Cedera :_______________

Jelaskan penyakit atau cedera secara rinci dan tunjukkan bagian tubuh yang terkena, mis. amputasi sendi indeks kanan: patah

tulang rusuk: keracunan timbal: dermatitis tangan kiri; dll

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Apakah karyawannya mati? Ya □ Tidak □ apakah karyawan kembali bekerja? Ya □ Tidak □

Jika karyawan tidak kembali bekerja, tunjukkan hari terakhir bekerja: ____________________________

Nama dan alamat dokter: _______________________________________________________________

Jika dirawat di rumah sakit, nama dan alamat rumah sakit: _____________________________________

Nama saudara perempuan: ______________________________________________________________

Komentar: ___________________________________________________________________________

Tanda tangan karyawan: _______________________________________________________________

Tanda tangan perawat atau orang P3K: ___________________________________________________

Tanggal: _____________________________________________________________________________