Laporan Kejadian Tumpahan dan Paparan Bahan Berbahaya dan Beracun (B3) dan/atau

Limbahnya

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

RINCIAN KEJADIAN

1. Nama yang terkena paparan:........................................................................................................

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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8. Analisa kejadian
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Pembuat Laporan : ................................... Penerima Laporan : ...................................
Unit : ................................... Unit : ...................................
Paraf : ................................... Paraf : ...................................
Tgl Lapor : ................................... Tgl terima : ...................................