FORM PENANGANAN KEKERASAN DI TEMPAT KERJA

A. Sumber Data (pilih salah satu dilingkari):

1. Laporan dari korban kekerasan
2. Temuan dari bagian SDI
3. Lainnya (sebutkan) ............................
B. Pihak yang terlibat:
1. ..........................................................
2. ..........................................................
3. ..........................................................
4. ..........................................................
C. Jenis Kekerasan (pilih salah satu dilingkari):
1. Kekerasan Seksual
2. Kekerasan Fisik
3. Kekerasan Psikis
4. Lainnya (sebutkan) ......................................................................................
D. Tempat terjadinya kekerasan ...............................................................................
E. Tanggal terjadinya
kekerasan ...............................................................................
F. Kronologis singkat ...............................................................................................
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G. Langkah-langkah penanganan dan penyelesaian:
1. ....................................................................................................................
2. ....................................................................................................................
3. ....................................................................................................................
4. ....................................................................................................................
5. ....................................................................................................................
6. ....................................................................................................................
H. Kesimpulan: ........................................................................................................
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Wonosobo, ....................................
Pihak terkait:

1. ......................................... 1. .....................................

2. ......................................... 2. .....................................

3. ......................................... 3. .....................................

4. ......................................... 4. .....................................