Lampiran Formulir Identifikasi Risiko
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8/18/2019 Lampiran Formulir Identifikasi Risiko
1/2
Form : 01 / UMR - 00
Puskesmas Kintamani 1
SAFETY, HEALTH E!"#R$!ME!T ALERT
T%&' Ke(a)ian : / /
*Date of Incident +
aktu : #TA
*Time+i&a.orkano&e / Reported By :Lokasi / Location : *Hazard + Pro.ert2 3aa2a,
4isin%, )&&
Tum.aan *Spill + 5as Me)ik Masa&a
AP *PPE Problems+
Pro4&em T' Ker(a Pro4&em Listrik Lain 6 Lain
*Others+
Rin7ian aa2a Yan% itemui :
*Detail of Findin Hazard +
Saran Tin)akanPer4aikan :
*S!estion for "orrecti#e $ction+
Su.er8isor / Dept Head :
Tan)aTan%an : Tan%%a& /
Date :
*Sinat!re+
A.aka arus )i.er4aiki se%era 9 #2a / %es
Ti)ak / &o
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8/18/2019 Lampiran Formulir Identifikasi Risiko
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*Sho!ld if be corrected immediately +
