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Formulir Laporan Kejadian Tumpahan dan Paparan

Bahan Berbahaya dan Beracun (B3)

RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAXIMAL 2 x 24 JAM

RINCIAN KEJADIAN

1. Nama yang terkena paparan:


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2. Unit kerja: ......................................................................................................................

3. Tanggal dan Waktu Insiden


Tanggal : ........................................................................................
Jam ......................................

4. Lokasi : ............................................................................................................................

5. Jenis Bahan: .....................................................................................................................

6. Kronologis Kejadian
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7. Tindakan yang dilakukan setelah kejadian:


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Pembuat Laporan : ................................... Penerima Laporan : ...................................


Dep/Unit : ................................... Dep/Unit : ...................................
Paraf : ................................... Paraf : ...................................
Tgl Lapor : ................................... Tgl terima : ...................................

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