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.
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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
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
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
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