IPT. ADHI KARYA (Persero) Tbk.

PROYEK RSUD CIBABAT CIMAHI

LAPORAN SEMENTARA KECELAKAAN

Nama : ____________________________________
Hari/Tanggal : ____________________________________
Jam : ____________________________________
Lokasi Kejadian : ____________________________________
Mandor / Perusahaan : ____________________________________
No. KTP : ____________________________________
Alamat : ____________________________________

Kronologis Kejadian :
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Kondisi / Anggota Tubuh yang mengalami Kecelakaan :

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Tindakan yang dilakukan / sudah dilakukan :

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CIMAHI……………….2012
Dibuat Oleh

Imam ks
Safety Officer