FORM KRONOLOGIS PESERTA KEJADIAN TRAUMA

Nama :..........................................................................................................
No Kartu JKN-KIS :..........................................................................................................
Status Kepesertaan :Peserta/Istri/Suami/Anak..................................................................
No BPJS Ketenagakerjaan:Ada/Tidak.........................................................................................
HP :..........................................................................................................
Alamat :..........................................................................................................
Pekerjaan :..........................................................................................................
Tanggal dan Jam Kejadian:..........................................................................................................
Lokasi Kejadian :..........................................................................................................
Rincian Kronologis :..........................................................................................................
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Dengan ini menyatakan bahwa informasi yang saya sampaikan di atas adalah benar dan saya
bertanggung jawab penuh secara hukum, jika dikemudian hari terbukti bahwa keterangan
yang saya berikan tersebut tidak benar (palsu).

Mengetahui, Lubuklinggau,
Dokter Pemeriksa Yang Membuat Pernyataan

Materai 6000

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FORM KRONOLOGIS PESERTA KEJADIAN TRAUMA