LEMBAR KERJA INVESTIGASI SEDERHANA

(GRADING HIJAU / BIRU)

Penyebab Langsung Insiden :

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Penyebab yang melatarbelakangi / akar masalah insiden :

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Rekomendasi Tanggal :

........................................................................................................................................................ Penanggung Jawab

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Tindakan yang akan dilakukan : Tanggal :

........................................................................................................................................................ Penanggung Jawab

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Manajer / Supervisor*

Nama Lengkap : ................................................................................ Tanda Tangan,

Tanggal mulai investigasi : ......................................

Tanggal selesai investigasi : ......................................

( ................................. )

Investigasi Lengkap : ................................... Ya / Tidak Tanggal : ............................

KOMITE MUTU
Diperlukan Investigasi lebih lanjut : Ya / Tidak

*Coret yang tidak perlu 008/F/KMT/SHBK/03/2021(Rev.00)

 LEMBAR KERJA ANALISA AKAR MASALAH (RCA)
(GRADING KUNING / MERAH)

1. Analisa terhadap KTD :

2. Tim RCA

Ketua Tim RCA :

Anggota (Pastikan :
semua area terkait
terwakili)

Petugas Pencatat :

3. Deskripsi singkat kejadian :

4. Faktor yang menjadi pencetus (Trigger) :

5. Kronologi kejadian :

*Coret yang tidak perlu 009/F/KMT/SHBK/03/2021(Rev.00)