PT.

Prosys Bangun Persada

LAPORAN KEJADIAN BERBAHAYA File No.
General Engineering & Construction Dangerous Occurrence Report
Doc No. SHES.F.004 Rev. 0 File Rev. Pages 1 / 2

HO Project : TUBAN IV Project No : 091427

Lokasi
Location
:
Tanggal Kejadian Waktu
: :
Date Occured Time

URAIAN KEJADIAN BERBAHAYA / MENDEKATI KECELAKAAN

DESCRIPTION IF NEAR MISS OR DANGEROUS INCIDENT

REKOMENDASI / TINDAKAN PERBAIKAN

RECOMMENDATIONS / CORRECTIVE ACTIONS

KETERLIBATAN PERSONIL / PERALATAN / MATERIAL

PERSONS/ EQUIPMENT / MATERIAL INVOLVED

Dibuat:/Prepared By :: Disetujui/Approved By:

PROJECT SAFETY OFFICER PROJECT MANAGER
Tanggal/ Tanggal/
D D
a a
t t
e e
: :

Diterima Oleh / Received By

CC:
PT. Prosys Bangun Persada
LAPORAN KEJADIAN BERBAHAYA File No.
General Engineering & Construction Dangerous Occurrence Report
Doc No. SHES.F.004 Rev. 0 File Rev. Pages 2 / 2