FORMULIR

FORMULIRLAPORAN ANCAMAN
LAPORAN BOM/BOM/
ANCAMAN
BOM
BOMTHREAT REPORT
THREAT FORM
REPORT FORM
Nomor Kasus / Case Number :…………………………………….
Nomor Kasus / Case Number :…………………………………….
RSU Avisena : ……………………………………
RSU Avisena : ……………………………………
INFORMASI YANG DITERIMA / INFORMATION :

Hari / Day : ………………………………….

Tanggal /Date : ………………………………….

Waktu / Time : ………………………………….

Penerima Informasi / Name of Recipient : ………………………………….

Kata –kata yang disampaikan pihak pengancam / words of the caller :

………………………………………………………………………………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………….…………………………………………………………

………………………………………………………………………………………………………………………………………………………………….…………………………………………………………

………………………………………………………………………………………………………………………………………………………………….…………………………………………………………

PERTANYAAN :

Dapatkan informasi scara taktis untuk mengetahui / Get the information tactically to find out :

1. Dimana letak bom / Where is the bomb location …………………………………………………………………………………………………………………………………

2. Bilamana akan meledak / When it will be burst ……………………………………………………………………………………………………………………………………
3. Bagaimana cirri bom / What is the typical of the bomb ……………………………………………………………..…………………………………………………………
4. System apa yang akan membuat bom meledak / What is the system of the bomb…………………….…………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………………………
5. Mengapa bom dipasang (alasannya) / What is the reason ……………………………………………………………………………………………………………………
6. Siapa yang memasang / Who’s responsible to the bomb …………………………………………………………..…………………………………………………………
7. Siapa yang menelpon / Who’s the caller ………………………………………………………………………..…………………………………………………………………….
8. Dimana penelepon dapat dihubungi / Contact number of the caller ……………………………………………………………………………………………………
9. Hal – hal yang perlu disampaikan / Other information’s of the caller ………………………………………..…………………………………………………………

GAMBARAN PENELPON / FEATURE OF THE CALLER :

1. Laki-laki/Perempuan / Man/Woman
2. Tua/Muda / Old/Young
3. Bangsa Indonesia/Asing / Indonesian/Foreigner
4. Suku / Clan ……………………………………….

SUARA / VOICE :

Cepat / Fast Jelas / Clear Sengau / Snuffle

Lambat / Slow Disamar /Covert Gagap / Impediment

Keras / Loud Tinggi / High Pecah / Burst

Lembut / Soft Berat / Hard Tehambat suatu benda / Cumber of Something

1
CARA BERBICARA / WAY TO SPEAK :

Tenang / Calm Berkelakar / Joke Takut-takut / Afraid

Emosional / Emotional Marah / Angry Tergesa-gesa / Precipitous

Meyakinkan / Convince Tidak Logis / Unlogic Gugup / Nervous

SUARA LATAR BELAKANG / BACKGROUND SOUND :

Lalu lintas / Traffic Pesawat Terbang / Plane Mesin / Machine

Musik / Music Orang Berbicara / Someone Talking Lain-lain / Others

SUARA DAPAT DIKENALI / THE VOICE IS RECOGNIZED :

1. Mirip Suara sdr/sdri / The voice resemble to mr/mrs ………………………………………………… atau suara / or voice of …………………………….……
2. Apakah tampaknya pengirim berita mengerti tentang keadaan/situasi didalam area / Is the caller seems know about situation pf the
area * :
Ya / Yes Tidak / No

Pelapor / Report by, Diperiksa Oleh / Verified by, Mengetahui / Acknowlodge by,

……………………………… …………………………………………. ……………………………………………

Nama Lengkap / Full Name DANRU / Security Staff Chief of Security

CATATAN :

*Coret yang tidak perlu / Streak on unnecessary word

Contreng (√) pada kotak yang sesuai / Mark (√) on the appropriate box