PROPERTY INCIDENT REPORT

Instructions:
 Document guest reports of injury or illness, property loss or damage, and crimes against persons or property.
 Document Hotel property loss or damage less than $10K. Immediately report damage exceeding $10K to 800-315-4625.
Use this form to:
(Hotels outside of Marriott’s Property Insurance Program should follow their Owners Insurance reporting protocol.)
 Document general incidents that impact Hotel operation.

 Document work-related injuries. Record work-related injuries on the Supervisor Accident Investigation Report (SAIR).
Do NOT use this form to:
 Document Hotel Fires or Carbon Monoxide incidents. Record those incidents on the Fire & Carbon Monoxide Incident Report.

Hotel Name: ALOFT BALI KUTA No. IR : D P S K A N o . 0 6 / A p r i l / 2 0 2 3

Type of Incident: X Injury/Illness Property Loss/Damage Crime General
Incident Date: April 27, 2023 Time of Incident: 09.20 AM Date Reported: April 27, 2023 Time: 0 9 . 2 1 A M

G UE ST IN F O RMA TI O N
Full Name: I Putu Adi Saputra Birth Date: June 30, 1997 X Male Female
Address: Jl Buana raya, Gang bhuana No. 4 Padangsambian, denpasar Room: -
Length of stay: -
City: Badung State: IDN ZIP Code:
Home/Cell Phone: 087776733177 Work Phone: - Email Address:
Purpose in Hotel: Talent
Source of Booking:

RE PO RT OF IN JURY
Mark an “X” for all appropriate responses below:
Strain/Sprain Inflammation Puncture Crushing injury Electric shock
Injury

Bruise/Contusion Concussion Dislocation Insect Bite Amputation

Cut/Laceration Scratch/Abrasion X Burn/Scald Fracture OTHER (specify):

Mark all appropriate known injury locations, and enter “R” for right, “L” for left, or “B” for both as appropriate:
Head Mouth Elbow (R/L/B): Finger Hip (R/L/B): Ankle (R/L/B):
Body part
affected

Eye (R/L/B): Neck/Throat Arm (R/L/B): Abdomen Thigh (R/L/B): Foot (R/L/B):

Ear (R/L/B): Chest: Wrist (R/L/B): Groin Leg (R/L/B): L Toe

Nose L Shoulder (R/L/B): L Hand (R/L/B): Back Knee (R/L/B): OTHER (specify):

First Aid: Offered & received Offered & declined Notes:

Treatment

Outside medical treatment: X Offered & received Offered & declined Notes:
Physician/Clinic/Hospital: Be Health Medika (Sheraton) Phone: (0361) 779900
Reported cause of injury: Bowl

Was area inspected immediately? Yes No If yes, by whom?

On what type of surface did the slip/fall occur? (e.g., tile, carpet, bathtub, stairs, etc.)
Slips/Trips/Falls

Did a foreign object or substance contribute to the slip/fall? (e.g., grease, water, object left on floor, etc.) Yes No
 If Yes, describe:
Did a weather- or maintenance-related condition contribute to the slip/fall? (e.g., ice, water, torn carpet, crack, etc.) Yes No
 If Yes, describe:
Was the person carrying anything when injured? Yes No If Yes, what was it?
Area last inspected or cleaned: Date: Time: By whom?
o
o

What was eaten? Date/time food was eaten:

F

Marriott International Proprietary & Confidential Version date: 12/12/2014 1

PROPERTY INCIDENT REPORT, conti nued

Reported symptoms: Date/time symptoms began:

d-Related
Illness
Food source (e.g., specify restaurant, room service, takeout/delivery, etc.
Notify the Foodborne Illness Hotline at 800-349-4469 if two (2) or more persons are suspected to have a foodborne illness. Additional information is
available on MGS: Foodborne Illness Notification Procedures.

Description of foreign object: Did you see the object? Yes No

object in
Foreign

Object was swallowed? Yes No Reported injury: Broken/chipped tooth Cut/laceration

food

Where is the object? Guest kept it Hotel has object, secured in (specify location):
Notes:

RE PO RT OF PRO PE RT Y LO SS
Description of property: Approximate value:
Where was the property last seen?
When was the property noticed to be missing? (day, date, time)
Did Marriott have custody of the item at the time of loss? Yes No
 If yes, describe (e.g., valet parked car, checked luggage, etc.):
Did the loss include forced entry or property damage? Yes No
 If yes, describe: Sofae Socver on Room guest
Did the loss occur within a guest room? Yes No
 If yes, obtain a Lock Interrogation and answer the following:
-Does the guest room have a safe? Yes No
-Did the loss occur from the safe? Yes No
Did the loss occur within a meeting room? Yes No
 If yes, was the meeting room door locked at the time of the loss? Yes No
Who was responsible for securing the room? Hotel upon request Guest No procedure established Other:

RE PO RT O F PRO PE RT Y DA MAG E
What was damaged? Approximate value of damaged property:
What caused the damage?

RE PO RT OF CRI ME
What was the crime?
Was an arrest made? Yes No If Yes, who was arrested?
Suspect information/notes:
Police &

Responding agency: EMS Police Police report #:

EMS

Notes:

Does surveillance video capture any elements of the incident? Yes X No  If yes, secure the video
Evidence

Are there photos pertaining to the incident? X Yes No  If yes, secure the photos and identify photographer below:
Photographer name: Imran Mahmuda Title: LP Supervisor
Is there physical evidence pertaining to the incident? Yes X No  If yes, secure the evidence

W IT N E SSE S
Name #1: Adi Karmawan Guest X Associate
Address: BCA pesona jadi Tabanan Phone: 081337895667
Name #2: Putu Adi Saputra Guest X Associate
Address: Padangsambian, Denpasar Phone: 08776733177
Name #3: Imran Mahmuda Guest X Associate
Address: Dalung Phone: 082251841872
Name #4: Danang Wijanarka Guest X Associate
Address: Padangsambian, Denpasar Phone: 081298912935

Marriott International Proprietary & Confidential 2

PROPERTY INCIDENT REPORT, conti nued

Marriott International Proprietary & Confidential 3

PROPERTY INCIDENT REPORT, conti nued

W IT N E SSE S
Name #5: dr. Tan Angellica Subianto Nurse X Doctor
Address: Denpasar Phone: 081328558841
Name #6: Ni Kadek Yuli Rindi Antika Nurse X Doctor
Address: Denpasar Phone: 087862089048

Brief facts of Incident:

On April 27, 2023 at 09.20 AM Danang (Head Chef) called Imran (Loss Prevention Supervisor) while helping to clean
the table, Danang informed that Adi Saputra (BnF Supervisor) had an accident. Adi was exposed to hot water from
the chicken noodle soup container brought by Adi Karmawan (Demi Chef De Partie). Imran immediately asked Adi to
take off his shirt and poured running water on his left arm for 2 minutes, (09.25 AM) then Imran referred Adi to the
in-house clinic Be Health Medika located at the Sheraton Bali Kuta Resort for intensive care.

Marriott International Proprietary & Confidential 4

PROPERTY INCIDENT REPORT, conti nued

The following statement has been made by:

 Imran Mahmuda (Loss Preventi on Supervisor)
Thursday, April 27, 2023 09.20 AM While I was helping breakfast at the depot, Danang (Head Chef)
called me and informed me that Adi Saputra (BnF Supervisor) got hot water from the chicken noodle
soup container brought by Adi Karmawan (Demi Chef De Parti e) . After that I went to Adi, asked Adi to
open his shirt and poured water on the upper left arm which was exposed to hot water for 2 minutes.
Next, I took Adi to the Be Health Medika in-house clinic at the Sheraton. (09.25 AM) Adi gets intensive
treatment from dr. Angellica (Doctor) and Nurse Yuli.
At the same ti me I informed Bayu (Human Resource Coordinator), James (Director Of Loss Preventi on)
and Komang Widyaputra (BnF Manager) about this incident.
 I Gede Komang Adi karmawan (Demi Chef De Parti e)
On April 27, 2023 at 09.20 AM During breakfast operati ons in the kitchen, when I was carrying chicken
noodle soup, I accidentally bumped into Adi Saputra (BnF Supervisor) because I didn't see him when I
left the kitchen area and headed for the corridor.
 I Putu Adi Saputra (BnF Supervisor)
This incident occurred when I was clearing up by carrying a plate to the steward area, I was hit by Adi
Karmawan (Demi Chef De Parti e) in the kitchen corridor, at that time Adi was carrying chicken noodle
soup and the broth hit my left arm directly .
 Danang Wijanarka (Head Chef)
I saw Putu Adi (BnF Supervisor) accidentally splashed with hot sauce brought by Adi Karmawan (Demi
Chef De Parti e). then I informed this to Imran (Loss Preventi on Supervisor) to be handled further
 dr. Angellica (Doctor Be Health Medika)
On April 27, 2023 at 09.25 AM at this morning, Aloft Bali Kuta employees came to the clinic for
treatment, the pati ent on behalf of Adi Saputra (BnF Supervisor), the pati ent said he was hit by boiling
hot water on his upper left arm up to his left wrist around +/- 5 minutes ago. When examining the
burn, it appears reddish, the burn experienced is a degree 1 burn +/- 4.5% Body Surface Area (BSA).
After carrying out the examination, the pati ent said he had a little pain and had rinsed with running
Narrative/Description

water for +/- 2 minutes. Aft er the compress and wound were dried, I applied bioplacenton ointment to
the injured area of the hand. Aft er fi nishing treating burns, we gave him 1 bioplacenton ointment for
wound care at home and gave him oral anestone for pain relief.
 Ni Kadek Yuli Rindi Antika (Nurse Be Health Medika)
On April 27, 2023 at 09.25 AM at this morning, Aloft Bali Kuta employees came to the clinic for
treatment, the pati ent on behalf of Adi Saputra (BnF Supervisor), the pati ent said he was hit by boiling
hot water on his upper left arm up to his left wrist around +/- 5 minutes ago. When examining the
burn, it appears reddish, the burn experienced is a degree 1 burn +/- 4.5% Body Surface Area (BSA).
After carrying out the examination, the pati ent said he had a little pain and had rinsed with running
water for +/- 2 minutes. Aft er the compress and wound were dried, I applied bioplacenton ointment to
the injured area of the hand. Aft er fi nishing treating burns, we gave him 1 bioplacenton ointment for
wound care at home and gave him oral anestone for pain relief.
Acti on Taken :
1. Gave first aid treatment, by providing poured water
2. Reffered Adi to in house clinic Be Health Medika
3. Report to Human Resource Department, B&F Manager & Director Of Loss Prevention

Conclusion :
(09.25 AM) After arriving at the Be Health Medika clinic, Adi received treatment and examination from dr. Angellica (Doctor)
and Yuli (Nurse), the treatments performed are as follows:
 Compressed with cold water for 10 minutes
 Given Bio Placenton ointment on all parts of the arm
 The doctor provides painkillers (Anastan Forte)
Based on the statement from dr. Angell, Adi burns are included in the category of 1st degree 4,5% Body Surface Area (BSA)
burns or occur in the epidermis.

Further corrective actions to prevent similar incidents from happening are as follows:
 Providing Kitchen Safety Tips (Imran and Danang) for all Culinary and B&F teams.
 Providing signage at kitchen corridor
 Ask Human Resources to provide burn ointment, such as Bioplacenton or Bepanthen in the first aid kit in the
Marriott International Proprietary & Confidential 5
PROPERTY INCIDENT REPORT, conti nued

ACTIVITY RECORD

1. The wound point

2. Treatment from Doctor and Nurse Be Health Medika and medicine

3. Conducted training to BnF Department and Culinary Department (Attendance Record Attached)

A PPRO VA LS/SI G N AT URE S

Claims Reporting Services notified? Yes No Date: - Time: - Claim #: -

Marriott International Proprietary & Confidential 6

PROPERTY INCIDENT REPORT, conti nued

Report completed by: (print name) IMRAN MAHMUDA Title/Position: Loss Prevention Supervisor
Signature: Date: April 27, 2023

Cluster Director of LP Dir of Operations Cluster Dir of HR General Manager

James Sitohang Daniel Bartolomeus Juliana Eka Putra Ashley Lai

Marriott International Proprietary & Confidential 7