Proyek :

______________________________________________________________________________________

Alamat :
______________________________________________________________________________________

LAPORAN KEBAKARAN

1. Tanggal/jam kejadian : ______________________________ 2. Pelapor :

______________________________

3. Ada tanda bahaya : Ya Tidak

4. Penerima laporan :
___________________________________________________________________________

5. Awal kebakaran di :
___________________________________________________________________________

6. Penyebab kebakaran :
___________________________________________________________________________

7. Besar api waktu awal ditemukan, jelaskan :

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_____________________________________________________________________

8. Bahan/barang yang pada awalnya terbakar :

___________________________________________________________

9. Usaha pemadaman yang dijalankan :

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
__________________

__________________________________________________________________________________________
__________________________________________________________________________________________
____________

Dilakukan oleh :
__________________________________________________________________________________

10. Alat Pemadam Api perusahaan yang dipakai :

 Alat Pemadam Api Type Ukuran Jumlah Keterangan
1. APAR
2. Karung Basah
3. Pasir
4. Hydrant
5. PMK
6.
7.
8.

1. Dilaporkan kepada : Owner Dinas Kebakaran Tidak Dilaporkan

Jam : ____________________________________________
2. Api dapat dikuasai, jam : ____________________________________________

3. Api dapat dipadamkan, jam : ____________________________________________

1/2

4. Kerusakan :

Nama barang atau bahan Besarnya kerusakan Nilai Kerugian (Rp.)

_________________________________ _______________________________ ____________________________

_________________________________ _______________________________ ____________________________
_________________________________ _______________________________ ____________________________
_________________________________ _______________________________ ____________________________

Jumlah : ____________________________
Uraian kejadian secara kronologis, skets dan foto :
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________

_____________________________________________________

Dilanjutkan dilembaran tambahan

5. Team penyelidik Nama Jabatan
 1.
2.
3.
4.
5.

6. Analisa team penyelidik :

__________________________________________________________________________

_____________________________________________________________________________________________
_____

_____________________________________________________________________________________________
_____

_____________________________________________________________________________________________
_____

Rekomendasi team penyelidik :

_________________________________________________________________________

_____________________________________________________________________________________________
_____

_____________________________________________________________________________________________
_____

_____________________________________________________________________________________________
_____

Dilaporkan oleh : Diketahui oleh :

Ketua Team / Safety Officer Project Manager

( _____________________________) ( _____________________________)