PEMERINTAH KABUPATEN BANGKALAN

UPT PUSKESMAS GEGER

Jln. Raya Pasar Lama Kombangan Kecamatan Geger 69152
Telp. 082172999119, 081936784712, 087816670869
Email: puskesmas.geger@gmail.com

LAPORAN KEJADIAN TUMPAHAN, PAPARAN/PAJANAN DAN INSIDEN LAINNYA

BAHAN BERBAHAYA DAN BERACUN (B3)

RINCIAN KEJADIAN

1. Nama yang terkena paparan/melaporkan : ................................................…………..

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2. Unit Kerja: ...................................................................................................................

3. Tanggal dan Waktu Insiden :

Tanggal : ..............................................Jam ...............................................................

4. Lokasi : .......................................................................................................................

5. Jenis Bahan: ...............................................................................................................

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6. Kronologis Kejadian:
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7. Tindakan yang dilakukan setelah kejadian:

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Pembuat Laporan : ................................... Penerima Laporan : ...................................

Unit : ................................... Unit : ...................................
Paraf : ................................... Paraf : ...................................
Tgl Lapor : ................................... Tgl terima : ...................................
 PEMERINTAH KABUPATEN BANGKALAN
UPT PUSKESMAS GEGER
Jln. Raya Pasar Lama Kombangan Kecamatan Geger 69152
Telp. 082172999119, 081936784712, 087816670869
Email: puskesmas.geger@gmail.com