First Aid Record Form
FIRST AID RECORD FORM
(Formulir P3K)
PERSONAL DETAILS:
(Data Pribadi)
Name (Nama) :........................................................ Address (Alamat):.................………….............................
Employer (Karyawan) :.......................................... Occupation (Pekerjaan).....................………………..........
Known Illness including medications:.......................……………...........................D.O.B........../............./.........
(Jenis Penyakit dan Obat-obatan)
INCIDENT/ACCIDENT DETAILS: INJURY/ILLNESS DETAILS:
(Detail Kejadian/Kecelakaan) (Detail Sakit/Cidera)
.............................................................................……..
Date/time :........................................................
(Tanggal/Waktu) ..............................................................................…….
Location:........................................................……….
(Lokasi)
INCIDENT OUTCOME:
Work process being performed:.....…….......……….. Kelas Kejadian
(Pekerjaan yang dilakukan)
.......................................................................………. Class I Class II Class III
Description of incident/accident:...................……… Causes (Kasus): …………................................................................
(Uraian Kejadian/Kecelakaan) ……
……………………………………………………….
…………………………………………………………
……………………………………………………….
Front Back
FIRST AID TREATMENT:
(Tindakan P3K)
.......…............................................………................
.................................................................………......
Date (Tanggal):....../....../......
__________________________________________
ACTION (Tindakan):
Back to Work (Kembali Kerja)
Hospital (Rumah Sakit)
Doctor/Clinic (Dokter/Klinik)
Reported to Supervisor (Lapor SPV)
Incident Report Required
(Buat Report Kejadian)
(INDICATE LOCATION OF INJURY)
Name (nama):..............................................……... MANAGER'S COMMENT:
(print name of person completing this form) (Komentar Manager) Yes No
(Tuliskan nama personel yang melengkapi) Has incident been investigated?
Address:.........................................................……. Apakah Kejadian sudah diselidiki?
(Alamat) Has Corrective Action been
.......................................................................……. implemented? Apakah Tindakan
Site Address (Nama Lokasi): Perbaikan sudah di lakukan?
……………………………….……. Has incident investigation report
……………………………………………………. been completed?
Apakah Laporan Investigasi
Kejadian sudah selesai?
..............................…………….
(Signature) ..................................................... ......................
Signature Date
Note :To be completed for all first aid treatments. Original forwarded to the OHS Manager at the end of each month
(Untuk Penyelesai Perawatan, Form Asli dikirim KE OHS manajer setiap Bulannya)
BAS.QHS-HSE-FRM-0007 First Aid Record Form Revisi : R0
