No.

Reg :
LAPORAN KECELAKAAN. Eff. Date :
ACCIDENT REPORT
Rev. No : 00

NAMA UMUR PERUSAHAAN

Name Age Company

SITE DEPARTEMEN JABATAN NO. KARYAWAN

Site Department Position Badge No.

TANGGAL KEJADIAN JAM LOKASI KEJADIAN

Date of Accident Time Place of Accident

PENGKAJIAN / PEMERIKSAAN
Medical Assessment
(Containing brief of chronology of the incident and trauma mechanism etc.)
-

DIAGNOSA / Diagnosis
( Describe it in the “general” terms and use Bahasa Indonesia e.g. “patah tulang paha kiri tertutup”
etc)
 No. Reg :
LAPORAN KECELAKAAN. Eff. Date :
ACCIDENT REPORT
Rev. No : 00

PENGOBATAN / Treatment
(Medical treatment required to the patient)

REKOMENDASI MEDIS KETERANGAN

Medical Recommendation Remarks
(Containing the medical recommendation including medical (Could be for time of treatment, etc.)
restrictions and planning and referral if required.) PLEASE DO
NOT STATE ANY SAFETY RELATED TERMS SUCH AS
LTI, RWDI, ETC.

Dibuat oleh Nama dr.Glorya S. C. Loei Tanda Tangan

Prepared Name Signature
by
ID No. MP 001 Tanggal/ Date 01 April 2020
 EXPOSURE INJURY AREA

E: 1,5 cm x 1 cm

NOTE:
C = Closed Fracture
O = Open Fracture
F = Foreign Body
L = Laceration
A = Abrasion
E = Ecchymosed (Bruising)
B = Burn (1st Degree Burn Injury)