FORMULIR PELAPORAN KEJADIAN KECELAKAAN TERTUSUK

BENDA TAJAM DAN PAJANAN CAIRAN TUBUH / ZAT KIMIA

I. IDENTITAS
NAMA : ..................................................................................
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UNIT
KERJA: ..........................................................................................
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II. RINCIAN KEJADIAN

1. Tanggal dan waktu insiden
a. Tanggal: ................................................................................
..............
b. Jam: .....................................................................................
.........
2. Insiden ( luka tusukan/
sayatan/percikan): ....................................................................
..............................
3. Kronologis
kejadian: ...................................................................................
...............
..................................................................................................
..................................................................................................
4. Tindakan yang dilakukan setelah
kejadian: ...................................................................................
...............
..................................................................................................
..................................................................................................
PEMBUAT LAPORAN: PENERIMA LAPORAN:

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TANGGAL DIBUAT: TANGGAL DITERIMA:

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PARAF: PARAF:

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