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Incident Notification Form

Incident Notification Form Template for Indonesia

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Key Requirements PROMPT example:

Incident Notification Form

"I need an Incident Notification Form for our manufacturing facility in Jakarta that complies with Indonesian workplace safety regulations, with additional sections for machinery-related incidents and integration with our digital reporting system."

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Document background
The Incident Notification Form is a crucial document required under Indonesian workplace safety regulations, particularly Law No. 1 of 1970 on Work Safety and Minister of Manpower Regulation No. 03/MEN/1998. This form must be completed whenever a workplace incident, accident, or near-miss occurs, serving as both an internal record and an official notification document for relevant authorities. The form ensures compliance with mandatory reporting timeframes and information requirements set by Indonesian law, while also facilitating proper incident documentation for insurance, investigation, and prevention purposes. It includes sections for immediate response actions, witness statements, and impact assessment, aligned with the requirements of the Occupational Safety and Health Management Systems (SMK3) under Government Regulation No. 50 of 2012.
Suggested Sections

1. Incident Reference Number: Unique identifier for the incident report

2. Reporter Details: Information about the person reporting the incident, including name, position, contact details

3. Incident Basic Information: Date, time, location, and type of incident

4. Affected Persons: Details of all persons involved in or affected by the incident, including employees, contractors, or members of the public

5. Incident Description: Detailed narrative of what occurred, including sequence of events

6. Immediate Actions Taken: Description of immediate response actions and emergency measures implemented

7. Witness Information: Details of any witnesses to the incident

8. Initial Assessment of Damage/Impact: Preliminary evaluation of any injuries, property damage, or other impacts

9. Notification Details: Record of when and how relevant authorities were notified

10. Declaration and Signature: Confirmation of accuracy and signature of the reporter

Optional Sections

1. Environmental Impact: Required when incident involves environmental damage or potential environmental risks

2. Equipment/Machinery Involved: Required when incident involves machinery or equipment failure

3. Third Party Information: Required when external parties or contractors are involved in the incident

4. Medical Response Details: Required when incident involves injuries requiring medical attention

5. Property Damage Assessment: Required when incident results in damage to property or assets

6. Business Continuity Impact: Required when incident affects business operations

Suggested Schedules

1. Incident Scene Photographs: Visual documentation of the incident scene and any relevant damage

2. Witness Statements: Detailed written accounts from witnesses

3. Medical Reports: Copies of initial medical assessments or treatment reports

4. Equipment/Machinery Inspection Reports: Technical reports for incidents involving equipment failure

5. Risk Assessment Form: Preliminary risk assessment conducted immediately after the incident

6. Incident Location Map/Floor Plan: Diagram showing where the incident occurred

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

Transportation and Logistics

Healthcare

Retail

Hospitality

Agriculture

Industrial Processing

Warehousing

Education

Chemical Processing

Food and Beverage

Pharmaceuticals

Technology

Infrastructure

Relevant Teams

Health and Safety

Human Resources

Operations

Risk Management

Compliance

Emergency Response

Security

Quality Control

Environmental Health

Production

Facilities Management

Project Management

Legal

Medical Services

Relevant Roles

Health and Safety Manager

HR Director

Facility Manager

Operations Manager

Site Supervisor

Line Supervisor

Production Manager

Risk Management Officer

Compliance Officer

Department Head

Plant Manager

Security Manager

Emergency Response Coordinator

First Aid Officer

Shift Supervisor

Quality Control Manager

Project Manager

Environmental Health Officer

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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