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Nearmiss, Unsafe Action, dan Unsafe Condition Report
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17
Questions
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1
Nama Pelapor
*
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2
Departemen
*
This field is required.
Produksi Line 1
Produksi Line 2
Produksi Line 4
QC
QS
QA
Engineering
Logistic
TS
MSTD
HRD-GA
FA
IT
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3
A. Kategori
*
This field is required.
Nearmiss / Hampir mengalami celaka
Unsafe Action / Perilaku Tidak Aman
Unsafe Condition / Kondisi Tidak Aman
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4
Personil yang terlibat kejadian
*
This field is required.
Saya Sendiri
Karyawan Lain
Vendor
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5
Nama Karyawan lain/Vendor yang terlibat Kejadian
*
This field is required.
N/A jika tidak ada
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6
Lokasi Kejadian
*
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7
Tanggal Kejadian
*
This field is required.
-
Date
Month
Day
Year
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8
Waktu Kejadian
*
This field is required.
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Menit
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9
Nama Saksi (Bila Ada)
*
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N/A jika tidak ada
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10
Perilaku / Kondisi Berisiko
*
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APD
Posisi & Perbuatan Seseorang
Kondisi Alat Kerja
Prosedur Kerja
Lingkungan
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11
Potensi Bahaya - Deskripsi Insiden
*
This field is required.
Bahaya yang akan timbul jika tidak dilakukan perbaikan
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12
Investigasi Nearmiss - Deskripsi Nearmiss
*
This field is required.
Deskripsikan Nearmiss/Unsafe Action/Unsafe Condition
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13
Tindakan Perbaikan
*
This field is required.
Berikan Rekomendasi Tindakan Perbaikan dari Anda
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14
PIC
*
This field is required.
Person in charge
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15
Due Date Perbaikan
*
This field is required.
Waktu penyelesaikan tindakan perbaikan
-
Date
Month
Day
Year
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16
Bukti Kejadian
Mohon dilengkapi dengan bukti kejadian seperti foto/dokumen
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
*Jika ada foto/bukti
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17
Tanda Tangan Pelapor
*
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Clear
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Should be Empty:
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