Form Investigasi k3

LAPORAN PENYELIDIKAN KEJADIAN / KECELAKAAN Jenis Kejadian

Kecelakaan kerja di lingkungan RS

Kecelakaan kerja di luar lingkungan RS

Kejadian lainnya

Lokasi Kejadian Sub Divisi / Unit Tanggal & Jam Kejadian Nama Korban / Peralatan Bagian Tubuh Yang Luka Cidera Yang Tampak Mata Alat Yang Menyebabkan Luka / Yang Menyebabkan Kejadian Serius Kerugian Yang Ditimbulkan Besar Kecil Kadang Kadang Jarang Kekerapan Dapat Terjadi Sering Kronologi Kejadian ................................................................................................................................................................................ ...................................................................................................................................(Terlampir1) Penyebab Langsung Kejadian dan Tindakan Yang Menyebabkan Kejadian ................................................................................................................................................................................ ....................................................................................................................................(Terlampir2) Penyebab Dasar / Utama Yang Disebabkan Faktor Manusia dan Peralatan ................................................................................................................................................................................ ....................................................................................................................................(Terlampir3) Tindakan Yang Perlu Dilaksanakan untuk menghilangkan penyebab diatas ................................................................................................................................................................................ ....................................................................................................................................(Terlampir4) Pelapor & Saksi : (TTD&Nama)

----------------------------Petugas K3 : (TTD&Nama)

-------------------------------------------------------Ketua PK3RS

: (TTD&Nama)

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Rekomendasi PK3RS : ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. ................................................................................................................. .................................................................................................................

Lampiran (1) Bagaimana Kejadian Dapat Terjadi : ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ Lampiran (2) Penyebab Langsung Kejadian dan Tindakan Yang Menyebabkan Kejadian : ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ Lampiran (3) Penyebab Dasar / Utama Yang Disebabkan Faktor Manusia dan Peralatan : ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ Lampiran (3) Tindakan Yang Perlu Dilaksanakan untuk menghilangkan penyebab diatas : ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................