R UM AH S AK IT C IT RA H US AD A Jl. Teratai No. 22 Jember Telp. (0331) 486200 Fax. (0331) 427088 Web : rscitrahusada.com Email :
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Laporan Kejadian Tumpahan dan Paparan Bahan Berbahaya dan Beracun (B3) RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAXIMAL 2 x 24 JAM RINCIAN KEJADIAN
1. Nama yang terkena paparan: ......................................................................................................................................... 2. Unit kerja: .................................................................................................................................... 3. Tanggal dan Waktu Insiden Tanggal : ........................................................................................ Jam ...................................... 4. Lokasi : ............................................................ ............ ................................................ ........................................................ ........................................................................... ................... 5.
Jenis Bahan: ...............................................................................................................................
6. Kronologis Kejadian ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... 7. Tindakan yang dilakukan setelah kejadian: ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... ....................................................................................................................................................... .......................................................................................................................................................
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Penerima Laporan
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Unit
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Paraf
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Tgl Lapor
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Tgl terima
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