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Contoh Form Laporan Kejadian



LAPORAN KEJADIAN
No.    .......................................


Pada hari ini ..................................... tanggal ........ bulan ......................... tahun ................. jam .............. WIB.

Nama                                       : .................................................................................
Jabatan                                     : .................................................................................

Yang sedang melakukan tugas sebagai __________________________ bahwa :

Hari / Tanggal               : .................................................................................
Pukul                                        : .................................................................................
Telah Terjadi                            : .................................................................................
                                                  .................................................................................
Lokasi Kejadian                       : .................................................................................
Penyebab Kejadian                  : .................................................................................
                                                  .................................................................................
Akibat Yang Ditimbulkan          : .................................................................................
                                                  .................................................................................
                                                  .................................................................................
Langkah Yang Diambil : .................................................................................
                                                  .................................................................................
                                                  .................................................................................
                                                  .................................................................................
                                                  .................................................................................
Saran-saran                              : .................................................................................
                                                  .................................................................................
                                                  .................................................................................

Demikian Laporan Kejadian ini saya buat dengan sebenarnya sesuai dengan apa yang saya lihat dan alami sebagai pertanggung jawaban tugas serta mengingat sumpah dan jabatan yang ada.


Jakarta, ...............................

Yang Membuat Laporan                                Saksi-saksi                            Mengetahui,




  ( ............................... )                       ( ............................... )             ( ............................... )




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Contoh Form Laporan Kejadian