No :

LOGO PT ACCIDENT / INCIDENT WITNESS Eff. Date :

REPORT Revision :
LAPORAN KESAKSIAN KECELAKAAN Page :

No. Laporan Kecelakaan

Tanggal (Dated):
(Accident Report No)
KECELAKAAN (Accidents)
Tanggal Kecelakaan
:
(Date of Accident)
Waktu Kecelakaan
:
(Time of Accident)
Lokasi Kecelakaan
:
(Location of Accident)

SAKSI (Witness)
Nama
:
(Name)
Umur
:
(Age)
Alamat
:
(Address)
Perusahaan
:
(Company)
KESAKSIAN

Dimana anda berada ?

Anda berada di lokasi Where is your position
sesaat sebelum
kecelakaan
Are You in Location a Apa yang anda lihat ?
minute before accident What is you see

Anda melihat
kecelakaan Apa yang anda lihat ?
Are you see the What is you see
accident

Apa yang anda lihat ?

What was you saw

Apa yang korban lakukan ?

Anda berada di lokasi What was the victim did
sesaat setelah
kecelakaan
Are you in location a
minute alter accident Apa yang anda lakukan ?
What was you did

Apa yang orang lain lakukan ?

What was the other people
did
 No :
LOGO PT ACCIDENT / INCIDENT WITNESS Eff. Date :
REPORT Revision :
LAPORAN KESAKSIAN KECELAKAAN Page :

Tanda Tangan Saksi : Tanda Tangan Interviewer :

Witness’ Sign Interviewer’s Sign

( ) ( )