PT.

SONOKEMBANG WAHANA JAYA

BERITA ACARA LAPORAN KEJADIAN FORM
Tanggal : 14 NOVEMBER
F25-600-101-B-XI-2022 Status Revisi : 00
2022
Disetujui oleh Direktur Operasional Dibuat oleh Supervisor HCGA Hal : 01/02

Pada hari ini................................... (Tgl/bln/th)...................................Saya yang bertandatangan di

bawah ini:

Nama : .......................................................................................................................................
NIP : .......................................................................................................................................
Jabatan : .......................................................................................................................................

Melaporkan kejadian sebagai berikut :

Hari, tanggal, waktu kejadian : ...............................................................................................................
Tempat Kejadian : ...............................................................................................................
Jenis Kejadian : ...............................................................................................................
Kronologi kejadian : ...............................................................................................................
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Dokumen ini milik PT Sonokembang Wahana Jaya Perubahan untuk perbaikan dilakukan dari waktu ke waktu. Dokumen ini tidak diperkenankan untuk digandakan atau disalin tanpa izin tertulis dari
manajemen PT Sonokembang Wahana jaya
 PT. SONOKEMBANG WAHANA JAYA
BERITA ACARA LAPORAN KEJADIAN FORM
Tanggal : 14 NOVEMBER
F25-600-101-B-XI-2022 Status Revisi : 00
2022
Disetujui oleh Direktur Operasional Dibuat oleh Supervisor HCGA Hal : 02/02

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Demikian Berita Acara Laporan Kejadian ini dibuat dengan sebenar – benarnya untuk dapat diproses
lebih lanjut sesuai peraturan dan prosedur pengamanan yang berlaku ditempat kerja.

Malang,...................,20....

Yang membuat laporan, Mengetahui,

(....................................) Amelia Boedinoegrahini

Supervisor HCGA

Dokumen ini milik PT Sonokembang Wahana Jaya Perubahan untuk perbaikan dilakukan dari waktu ke waktu. Dokumen ini tidak diperkenankan untuk digandakan atau disalin tanpa izin tertulis dari
manajemen PT Sonokembang Wahana jaya