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Employee Incident Report Form Template for Indonesia

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Key Requirements PROMPT example:

Employee Incident Report Form

"I need an Employee Incident Report Form for our manufacturing facility in Jakarta that complies with Indonesian regulations, with extra emphasis on machinery-related incidents and a simplified Bahasa Indonesia translation for our factory workers."

Document background
The Employee Incident Report Form is a crucial document required under Indonesian workplace safety regulations, specifically aligned with Law No. 13/2003 on Manpower and Law No. 1/1970 on Work Safety. This form must be completed whenever a workplace incident occurs, ranging from minor accidents to serious injuries or near-misses. It serves multiple purposes: documenting the incident details for internal records, fulfilling legal reporting requirements, supporting insurance claims with BPJS (Social Security Administrative Bodies), and contributing to workplace safety improvement initiatives. The form includes sections for incident description, witness statements, immediate actions taken, and follow-up measures, making it an essential tool for risk management and legal compliance in Indonesian workplaces.
Suggested Sections

1. Report Identification: Unique report identifier, date and time of report completion, and document control information

2. Incident Details: Date, time, location, and type of incident

3. Employee Information: Details of the affected employee(s) including name, employee ID, department, role, and contact information

4. Incident Description: Detailed narrative of what occurred, including sequence of events and immediate actions taken

5. Witness Information: Names and contact details of any witnesses to the incident

6. Injury/Damage Assessment: Description of any injuries sustained or property damage incurred

7. Immediate Response Actions: Steps taken immediately following the incident, including first aid or emergency response

8. Supervisor's Review: Immediate supervisor's assessment and verification of the incident details

9. Root Cause Analysis: Initial assessment of what led to the incident

10. Corrective Actions: Immediate and planned actions to prevent recurrence

Optional Sections

1. Environmental Impact: Assessment of any environmental effects - required for incidents involving chemical spills or environmental hazards

2. Equipment/Machinery Involved: Detailed information about any equipment or machinery involved in the incident - required for equipment-related incidents

3. Third Party Involvement: Information about any contractors, visitors, or external parties involved - required when non-employees are affected

4. Medical Report Section: Detailed medical assessment and treatment information - required for incidents resulting in significant injury

5. Cost Impact Assessment: Evaluation of financial impact including property damage, lost time, and other costs - required for major incidents

6. BPJS Notification Details: Specific information required for social security reporting - required for incidents requiring BPJS notification

Suggested Schedules

1. Incident Scene Photographs: Labeled photographs documenting the incident scene and any visible damage or hazards

2. Witness Statements: Detailed written accounts from witnesses, signed and dated

3. Medical Documentation: Copies of relevant medical reports or first aid records

4. Risk Assessment Form: Updated risk assessment for the activity/area involved in the incident

5. Equipment Inspection Records: Relevant maintenance or inspection records for any equipment involved

6. Investigation Checklist: Standard checklist to ensure all necessary investigation steps are completed

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok成人版 | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

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Relevant Industries

Manufacturing

Construction

Mining

Oil and Gas

Transportation and Logistics

Healthcare

Retail

Hospitality

Agriculture

Chemical Industry

Automotive

Food Processing

Pharmaceuticals

Warehousing

Education

Facilities Management

Relevant Teams

Human Resources

Health and Safety

Operations

Facilities Management

Risk Management

Compliance

Production

Quality Control

Security

Emergency Response

Occupational Health

Legal

Administration

Relevant Roles

Health and Safety Manager

HR Director

Facility Manager

Operations Manager

Department Supervisor

Risk Management Officer

Compliance Officer

Production Supervisor

Line Manager

Shop Floor Supervisor

Site Manager

Quality Control Manager

Plant Manager

Safety Engineer

Occupational Health Nurse

Security Manager

Emergency Response Coordinator

Industries






Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks, 聽Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination, 聽Severance Pay, Governing Law, Entire Agreemen

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