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  • Insiden Report

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    Eyla Rahajeng
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    This incident report document is from RSIA Fauziah hospital in Tulungagung, Indonesia. It requests information about a non-patient incident including the type of incident, details of the victim, location and time of the accident, a description of what happened, whether protective equipment was worn, and the condition of any injuries. The document must be filled out and signed by the relevant unit and occupational safety team.

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    This incident report document is from RSIA Fauziah hospital in Tulungagung, Indonesia. It requests information about a non-patient incident including the type of incident, details of the victim, location and time of the accident, a description of what happened, whether protective equipment was worn, and the condition of any injuries. The document must be filled out and signed by the relevant unit and occupational safety team.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    107 views1 page

    Insiden Report

    Uploaded by

    Eyla Rahajeng
    This incident report document is from RSIA Fauziah hospital in Tulungagung, Indonesia. It requests information about a non-patient incident including the type of incident, details of the victim, location and time of the accident, a description of what happened, whether protective equipment was worn, and the condition of any injuries. The document must be filled out and signed by the relevant unit and occupational safety team.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    LAPORAN INSIDEN

    (INCIDENT REPORT)
    RSIA Fauziah
    Jl. Dr. Sutomo no. 47
    Tulungagung

    Laporan Insiden Selain Pasien

     Jenis Insiden
    Near Miss Kecelakaan Kerja Gangguan Kesehatan Tumpahan B3
    Kebakaran Gangguan Keamanan Lain- lain, sebutkan…….
    A. Keterangan tentang Tenaga Kerja Penderita (Personal Data of The Fictim)
    1. Nama :………………………………………………………………………………………………………
    2. Tanggal Lahir :………………………………………………………………………………………………………
    3. Jenis Kelamin :………………………………………………………………………………………………………
    4. Alamat :………………………………………………………………………………………………………
    5. Jenis pekerjaan :……………………………………………………………………………………………………..
    B. Tempat dan Waktu Terjadinya Kecelakaan
    1. Tempat :………………………………………………………………………………………………………………..
    2. Tanggal :………………………………………………………………………………………………………………..
    3. Pukul :………………………………………………………………………………………………………………..
    C. Uraian Terjadinya Kecelakaan
    ………………………………………………………………………………………………………………………………………..
    ………………………………………………………………………………………………………………………………………..
    D. Korban memakai Alat Pelindung Diri : Ya Tidak
    Alas an tidak memakai : ………………………………………………………………………………………………..
    ………………………………………………………………………………………………………………………………………..
    E. Keterangan yang Nampak Mata Tentang Keadaan Luka – luka Penderita
    ………………………………………………………………………………………………………………………………………..
    ………………………………………………………………………………………………………………………………………..
    ………………………………………………………………………………………………………………………………………..

    Tulungagung, ……………………………………..
    Mengetahui,
    Dilaporkan oleh Unit Terkait Tim K3

    (…………………………………..) (…………………………………..)

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