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  • Formulir Pelaporan Kecelakaan Kerja

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    FORMULIR PELAPORAN KECELAKAAN KERJA

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    16 views1 page

    Formulir Pelaporan Kecelakaan Kerja

    Uploaded by

    Khoyyimah

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    PEMERINTAH KABUPATEN SUMENEP

    DINA KESEHATAN PENGENDALIAN PENDUDUK


    DAN KELUARGA BERENCANA
    PUSKESMAS BATANG-BATANG
    Jl.Cemara Udang No. 3 Batang-Batang Telp. 0328 – 511269
    Email : puskesmasbatang2@gmail.com
    SUMENEP
    Kode Pos : 69473

    FORMULIR PELAPORAN KECELAKAAN KERJA

    1. NAMA :
    2. UMUR :
    3. ALAMAT :
    4. INSTALASI/UNIT KERJA :
    5. TEMPAT KEJADIAN :
    6. PETUGAS : KARYAWAN / PENDERITA / PENGUNJUNG
    7. TANGGAL KEJADIAN :
    8. KRONOLOGIS KEJADIAN :

    9. ALAT PELINDUNG DIRI YANG DIPAKAI :

    10. CIDERA YANG DI DAPAT :

    11. TINDAKAN YANG DILAKUKAN :

    Sumenep,…………………2022
    Kepala Puskesmas Batang-Batang

    dr. Fatimatul Insyoniah, M.Kes


    NIP. 19750804 200501 2 009

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