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  • HSE-AI-004 - First Aid Case Report Form

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    seroja oja
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    This document is an industrial accident/incident report form for a first aid case. It collects information about the injured person such as name, ID number, nationality, age, and company. It documents the incident location, type of injuries, any property damage, and a description of the incident. The form also identifies the root causes of the incident and any corrective actions taken.

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    This document is an industrial accident/incident report form for a first aid case. It collects information about the injured person such as name, ID number, nationality, age, and company. It documents the incident location, type of injuries, any property damage, and a description of the incident. The form also identifies the root causes of the incident and any corrective actions taken.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    23 views1 page

    HSE-AI-004 - First Aid Case Report Form

    Uploaded by

    seroja oja
    This document is an industrial accident/incident report form for a first aid case. It collects information about the injured person such as name, ID number, nationality, age, and company. It documents the incident location, type of injuries, any property damage, and a description of the incident. The form also identifies the root causes of the incident and any corrective actions taken.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    PT Nexelite CP Indonesia HSE-AI-004

    BKM Group of Companies (Corrosion Prevention)

    Industrial Accident/Incident Report


    First Aid Case
    Name of Injured Personnel (Orang yang terluka) Date / Time of Injury:
    Tanggal/waktu kecelakaan

    Incident Location (Lokasi kejadian) ID/KTP Number: Nationality (kebangsaan)

    DOB/Age: Umur dan Tgl Lahir Helm Number:

    Company/Sub-con: Section /Trade (Bagian/keterampilan)

    Type of Injuries (Jenis kecelakaan) Property Damage (If any) Kerusakan properti (jika ada)

    Description of Incident (Deskripsi kejadian)

    Root Cause of the Incident (Penyebab kejadian):


    - Unsafe condition :

    - Unsafe Action :

    Corrective Action Has Been Taken: Tindakan tepat yang telah dilakukan

    Name/Signed: Card No:

    Job Title: Date of Report:

    Company:

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