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Contoh Incident Report Word PDF
Contoh Incident Report Word PDF
Contoh Incident Report Word PDF
INFORMATION OF LOCATION
o Name of Location :
o Name of Client :
o Total Project Cost :-
o Project Period :-
o Name of Project Manager :
o Name of HSE SPV :
GENERAL INFORMATION
o When :
o Where :
o Who :
o What :
o why :
how :
o Severity of Incident :
o Material damage : -
Name :
Nationality : NIK KTP :
Job Category :
Address :
Company : Work type :
Name of Hospital :-
o Report by :
Kord. HSE 3D HSE SPV DM HSE MK 3D Deputy MP
*This report must be made by Project team section and sent to HSRCC within 1 x 24 hours after the incident as initial report
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INITIAL PHOTO REPORT
Dokumentasi DT
Page 2 of 11
FINAL INCIDENT REPORT
Name of Division PT WIKA
Location
Date/ time DMP
of incident
Place of DM HSE
incident
Category of MK
incident
Project Period - Progress rate - HSE SPV
Cause of
incident
(describe in
detail by
5W1H
method)
o Decription of damaged :
Page 3 of 11
-
Conclusion
after
Investigation :
Attachment : Incident time sequence, investigation report, incident place sketch, incident picture, witness statement,
Supervisor/ Foreman statement, victim self statement.
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FINAL PHOTO REPORT
FOTO 1
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SEQUENCE OF INCIDENTS
Time Sequences
09.30
09.45
10.50
11.05
INCIDENT TIMELINE
11:15
11:20
11.30
14.35
16:15
*This initial report must be made and sent to HSRCC within 1 x 24 hours after the incident
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FOLLOW UP ACTION PHOTO
FOTO 1
FOTO 2
Page 7 of 11
VICTIMS SELF STATEMENT
Name Departement
Gender Nationality Company
Job Category Date Hire -
Task on time of incident
Name of worker worked together in
time of incident
o When :
o Where :
o Who :
o What :
o why :
o how :
o Material damage : -
Name :
Nationality : NIK KTP :
Job Category :
Address :
Company : Work type :
Page 8 of 11
WITNESS STATEMENT
o Indirect Cause
Johan
( SO )
Page 9 of 11
Page 10 of 11
WORKER STATEMENT
Information of Division Job Category
Witness Name Position
Task taken
Involved
Information of Equipment
Task on Incident
Number of
Workers Involved
KETERANGAN
Witness
description
Description of
atitude
Description of
victim condition
Others
-
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