DOCTORS STATEMENT LETTER ACCIDENT REPORT LAPORAN KECELAKAAN KERIA Nama korban Kewarganegaraan Injured Personnel (IP) Nationality Tadloa en Pekerjaan Umur Occupation Age JenisKelamin Nomer ID. Gender IDNo. Alamat Telepon Address Phone no. Perusahaan Tempat kejadian Company * Location of accident Nama Supervisor Tanggal &Waktu Superisors name . Date & Time Le. Desensé zoe 5-98 Perawatan & obat-obat yang diberikan Keterangan tentang luke-lukanya Treatment(s) & Care(s) Detail of Injured ~ Priden Tedine (Betadine Soletron).| - luke wor 2 ge hake bagiod Feo (ne ((esencOiel nate er ®) feelers a = menor At aren Uhut bobet Rekomendasi atau Pembatasan Medis kent bagien Luar, Medical Recommendation or Restriction Dapat kembali bekerja _ Mayreturn to work Perluistirahat selama Need rest for i Day(s) Perlu dirujuk ke rumah Refer to hospital/ other sakit/ faslitas medis yg medical facility fain Uraian terjadinya kecelakaan, Chronology of Accident Saat Gedlawp. us posgewren thatthe cocrete dawn concrete. Pump anblas ke denypat harbor mentee teanglaindor dx terbentr OF bagian bat’ he Date of Check Checked by Doctor a _ Ay] = Meeligal Section : poet T