Nama Formulir Berita Acara Kejadian

No Formulir Form-BP-HSE-008
Revisi 00
Jobsite Banjarsari – Lahat, Sumsel Tanggal Efektif 01 Januari 2017
Halaman 2 dari 2

BERITA ACARA KEJADIAN

Yang bertanda tangan dibawah ini :

Nama : ____________________________________________
Jabatan : ____________________________________________
Departement : ____________________________________________
No. Kimper/ID : ____________________________________________

Dengan ini memberitahukan bahwa telah terjadi Kecelakaan pada:

Hari : ____________________________________________
Tanggal : ____________________________________________
Waktu : ____________________________________________
Lokasi : ____________________________________________
Unit/Orang : ____________________________________________

1. Kronologis Kejadian
Jelaskan penyebab kejadian secara rinci dari awal hingga akhir.
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 Nama Formulir Berita Acara Kejadian
No Formulir Form-BP-HSE-008
Revisi 00
Jobsite Banjarsari – Lahat, Sumsel Tanggal Efektif 01 Januari 2017
Halaman 2 dari 2

2. Akibat dari Kejadian:

- Terhadap Manusia : ___________________________________________________

- Terhadap Lingkungan : __________________________________________________

- Terhadap Alat/Unit : __________________________________________________

Demikian berita acara ini dibuat, dengan sebenar-benarnya.

________________________ , _____/_________________/__________
Dibuat Oleh, Diketahui Oleh,

(________________________) (___________________________)