Form : 01 / MR - 00

UPT. PUSKESMAS KLUNGKUNG I

SAFETY, HEALTH & ENVIRONMENT ALERT

Tgl. Kejadian : / / Waktu : WITA
(Date of Incident) (Time)
Dilaporkan oleh / Reported By :
Lokasi / Location :
B3 (Hazard) Property Cahaya, bising, dll
Tumpahan (Spill) Gas Medik Masalah APD (PPE Problems)
Problem T. Kerja Problem Listrik Lain – Lain (Others)
Rincian Bahaya Yang Ditemui :
(Detail of Finding Hazard)

Saran Tindakan Perbaikan :

(Suggestion for Corrective Action)

Supervisor / Dept Head :

Tanda Tangan : Tanggal / Date :

(Signature)
Apakah harus diperbaiki segera ? Iya / Yes Tidak / No
(Should if be corrected immediately)