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Hazard Incident Report Form

Hazard Incident Report Form Template for Indonesia

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Key Requirements PROMPT example:

Hazard Incident Report Form

"Need a comprehensive Hazard Incident Report Form for our chemical manufacturing facility in Jakarta, with specific sections for chemical spills and exposure tracking, plus integration with our digital HSE management system to be implemented by March 2025."

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Document background
The Hazard Incident Report Form is a crucial document required under Indonesian workplace safety legislation, specifically aligned with Law No. 1 of 1970 and related regulations. This form should be used whenever a workplace incident occurs, including accidents, near-misses, property damage, or environmental incidents. It serves multiple purposes: documenting the incident details for legal compliance, initiating internal investigations, supporting insurance claims, and contributing to organizational learning and risk prevention. The form requires input from various stakeholders and must be completed promptly after an incident occurs, typically within 24 hours. It forms part of the organization's broader safety management system and may be subject to review by government authorities during safety audits.
Suggested Sections

1. Report Identification: Unique report number, date and time of report creation, and facility/location identifier

2. Incident Details: Date, time, location, and type of incident (near-miss, accident, injury, property damage, environmental)

3. Reporter Information: Name, position, contact details, and department of the person reporting the incident

4. Affected Persons: Details of all people involved, including injured parties, witnesses, and other affected individuals

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

6. Injury/Damage Assessment: Description of injuries sustained or property/environmental damage, including severity classification

7. Immediate Response Actions: Steps taken immediately after the incident, including emergency response and medical treatment

8. Root Cause Analysis: Initial assessment of what caused the incident, including contributing factors

9. Corrective Actions: Immediate and planned corrective actions to prevent recurrence

10. Notifications Made: List of internal and external parties notified (management, authorities, emergency services)

11. Verification: Signatures and verification by responsible parties (reporter, supervisor, HSE officer)

Optional Sections

1. Environmental Impact: For incidents involving environmental releases or impacts, detailed assessment of environmental damage and containment measures

2. Equipment/Machinery Involved: For incidents involving equipment failure or machinery accidents, detailed information about the equipment and its maintenance history

3. Chemical Exposure: For incidents involving hazardous substances, details of chemicals involved, exposure levels, and MSDS reference

4. Contractor Involvement: When contractors are involved in the incident, additional details about contractor company and their safety procedures

5. Production Impact: For incidents affecting production processes, assessment of operational impact and downtime

6. Cost Assessment: Preliminary assessment of costs related to damage, repairs, or business interruption

7. Insurance Information: For incidents requiring insurance claims, relevant insurance policy and claim details

Suggested Schedules

1. Incident Scene Photographs: Visual documentation of the incident scene, damage, or hazardous conditions

2. Witness Statements: Detailed statements from witnesses, recorded on standard witness statement forms

3. Medical Reports: Copies of initial medical assessment reports or first aid records

4. Risk Assessment Matrix: Standard risk assessment matrix for incident classification and severity rating

5. Site Plan/Layout: Marked-up site plan showing incident location and relevant details

6. PPE Checklist: Checklist confirming PPE usage and compliance at time of incident

7. Investigation Timeline: Detailed timeline of events leading to and following the incident

8. Regulatory Reporting Requirements: Checklist of mandatory reporting requirements under Indonesian regulations

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

alex.den.21@genieai.co
Relevant legal definitions








































Clauses
























Relevant Industries

Manufacturing

Construction

Mining

Oil and Gas

Chemical Processing

Agriculture

Transportation and Logistics

Warehousing

Food Processing

Pharmaceuticals

Automotive

Aerospace

Shipbuilding

Energy Generation

Waste Management

Healthcare

Heavy Industry

Forestry

Metal Processing

Textiles

Relevant Teams

Health Safety Environment

Operations

Production

Maintenance

Quality Control

Risk Management

Compliance

Security

Emergency Response

Facilities Management

Human Resources

Occupational Health

Environmental Management

Training and Development

Legal

Senior Management

Relevant Roles

Health and Safety Manager

HSE Officer

Site Supervisor

Plant Manager

Operations Manager

Production Supervisor

Maintenance Engineer

Quality Control Inspector

Risk Manager

Compliance Officer

Security Manager

Emergency Response Coordinator

Facility Manager

Department Head

Shift Supervisor

Safety Committee Member

Environmental Officer

Human Resources Manager

Occupational Health Nurse

Safety Trainer

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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