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LAPORAN KEJADIAN TUMPAHAN DAN PAPARAN

BAHAN BERBAHAYA DAN BERACUN (B3)

RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAKSIMAL 2 X 24 JAM

RINCIAN KEJADIAN
1. Nama yang terkena paparan : .............................................................................................
2. Unit Kerja : .............................................................................................
3. Tanggal : .................................................. Jam : ........................................................
4. Lokasi : .....................................................................................................................
5. Jenis Bahan : .....................................................................................................................
6. Kronologis kejadian
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7. Tindakan yang dilakukan setelah kejadian :
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Pembuat Laporan : ........................... Penerima Laporan : .............................
Unit Kerja : ........................... Unit Kerja : .............................
Paraf : ........................... Paraf : .............................
Tanggal Lapor : ........................... Tanggal Terima : .............................