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BERITA ACARA KECELAKAAN KERJA

Yang bertanda tangan dibawah ini :


Nama : ............................................................................................................
Jabatan : ............................................................................................................
Menerangkan dengan sebenarnya bahwa telah terjadi kecelakaan yang menimpa petugas :
Nama : ............................................................................................................
Alamat : ............................................................................................................
Tempat Tanggal Lahir : ............................................................................................................
Bagian/ Unit : ............................................................................................................

Adapun uraian kejadiannya adalah sebagai berikut :


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Demikian Berita Acara ini dibuat dengan sebenarnya untuk dipergunakan sebagaimana
mestinya.

Depok, ……………....
Yang menerangkan Saksi I Saksi II

(…………………..) (…….……………) (……….………….)

Mengetahui,
Ketua Komite K3RS

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

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