Diisi oleh pelapor (Filled by reporter) Foto/sketsa jika ada (Photo or sketch, if any)

AnOMALY/CeRMAT Saran pencegahan&perbaikan (Suggestion for

prevention&improvement):

Diisi oleh pelapor (Filled by reporter)

Uraian (Details):

Diisi jika diperlukan (Filled if required)

Perlu informasi tindak lanjut (Require feedback)? [ ] Ya/Yes [ ] Tidak/No
Nama (Name):
Bagian (Entity): HSSE Perusahaan (Co.): PT.
E-mail: hsse@pt-ppi.com
Atasan Pelapor (Line Supervisor) :
Bagian (Entity): Site engineer Td. Tangan (Signature):
Diisi oleh Coordinator K3LL dan RSES (Filled by HSSE Coordinator )

Lokasi (Site): Daerah (Area): [ ] For Statistic Purpose [ ] Register in Synergi No: _______5
Tanggal (Date): Jam (Time): Potential Severity (1-5): ______________________________________
Tindakan langsung yang dilakukan (Immediate action taken): For INCIDENT: Real Severity (1-5): _________ Classification: HUMAN
INJURY
Giving commemoration so that tomorrow changing. Date: Signature&Name:
RSES recommendations/actions:
(Action Description - Responsible for Action (By) - Target Date)
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Penyebab langsung (Immediate causes):

Date: Signature&Name:
CeRMATi sekeliling anda untuk meningkatkan keselamatan. Do CeRMAT in your surrounding to improve safety.