Nama : ....................................Jabatan :.....................................................................
Yang sedang melakukan tugas sebagai __________________________bahwa :
Hari /Tanggal:............................................Pukul : ................wib
Telah
terjadi ................................................................................. ........
.....................................................................................................................................
...........................................
Lokasi:.........................................................................................................................
Penyebab
kejadian: ................................................................................. ....................................
..............Akibat Yang
ditimbulkan: ................................................................................. ..............................
................................................... .................................................................................
.....................
Langkah Yang
diambil: ................................................................................. .....................................
.....................................................................................................................................
..............
.................................................................................Saran-
saran: ................................................................................. .........................................
........................................ .................................................................................Demik
ian Laporan kejadian ini saya buat dengan sebenarnya sesuaidengan apa yang saya
lihat dan alami sebagai pertanggung jawaban tugas serta mengingat sumpah dan
jabatan yang ada.
Magelang ...............................