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FORMULIR PELAPORAN INSIDEI'i/KETI DAKSEST]AI ATi K3L

Itol,lOR FOR'IIX.IR
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INFORMASI TENAGA KERJA

t{.m t€ngl€p

Ab.Bt Tenrpd Inggd

l6b Kelamin (VP)

ttnur

Nm Induk

8.96

labah

Telep6

DESI(RIPSI CIDERA / INSIDEN

Hri/fmgqau8uho/rdrun

waldu (Arhrl) (wI8, Wrr, wrTA)

tlm Pehpq Ioritcn Lben do lrdw Tdepo

s.li lilg$ng li**o Jab.Ei d.ri lldw Tlkps

(&!ci Inir6 f] l- fi$ / sit r* sat h.16 (86pd!oi isE bdm ced6a lbu faugln at ecrEftu) E] tdTre(lbendeipckrriulq@ed@)

E fi* fu (ntcn*,rt*loo p6|9ob&i s96., lpsri pab..r, brT.6 diBh) tf HalhCa.!(p6gobdtoldtpct4auld6)

9erEob.t i oeds. E ru*rao E Oe*ixi C€d@ (b.q!s trbuh Flg @d6., lDodii edera) :

fI gotUqtg{thrtrrt f-l rrmtr -*t / paryro orrur*

kixi pqtdoigs pert m 1aq diberior :

ANALTSIS/ PEREAIXA'{ INSIOEN

(,sobgir Kej.dln / Fsi.nrc

knfbab Inido / tct*faan

lhbd INd6 / Knlhkm

Ladoh M.*a

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Ohpo*r olcr,

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