TINDAKAN SEGERA YANG NILAI

BAHAYA YANG DITEMUKAN

(HAZARD FOUND) DILAKUKAN RISIKO
(RISK VALUE)
(IMMEDIATE ACTION TAKEN)
Tanggal (Date) : ____________________________ ___________________________________ L :
Tempat (Location) : ____________________________ ___________________________________ S :
Detail Bahaya (Detail of Hazard) R :
LAPORAN BAHAYA

___________________________________
(HAZARD REPORT)

_____________________________________________________ ___________________________________
_____________________________________________________ ___________________________________ KODE
BAHAYA
_____________________________________________________ ___________________________________ (HAZARD CODE)

_____________________________________________________ ___________________________________ AA
_____________________________________________________ ___________________________________ A
_____________________________________________________ ___________________________________ B
C
Penemu Bahaya (Observer) Tanda Tangan
Telah Dilaporkan Lisan Kepada (Reported by Verbal To)
(Signature)
Nama Nama
(Name) : _________________ (Name) : _______________________
Jabatan Jabatan
(Position) : _________________ (Position) : _______________________
Bagian Tanggal
(Department) : (Date) :