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Incident Investigation Form Template for Indonesia

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Key Requirements PROMPT example:

Incident Investigation Form

"I need an Incident Investigation Form for our chemical manufacturing plant in Jakarta that includes detailed sections for hazardous material exposure and environmental impact assessment, with specific reference to Indonesian chemical industry safety regulations and BPJS reporting requirements."

Document background
The Incident Investigation Form is a crucial document required under Indonesian workplace safety regulations, specifically aligned with Law No. 1 of 1970 on Work Safety and Government Regulation No. 50 of 2012 on SMK3. This form must be completed following any workplace incident, near-miss, or accident to document the event, identify root causes, and establish preventive measures. It serves multiple purposes including regulatory compliance, insurance documentation, and workplace safety improvement. The form is designed to capture comprehensive information about the incident, from initial occurrence through to final recommendations, and must be maintained as part of the company's safety records. It's particularly important for fulfilling reporting obligations to relevant Indonesian authorities and supporting potential workers' compensation claims through BPJS Employment.
Suggested Sections

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

2. Affected Person(s) Details: Information about individuals involved including employees, contractors, or visitors

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

4. Immediate Actions Taken: Emergency response measures and immediate steps taken after the incident

5. Witness Information: Details of witnesses and their initial statements

6. Investigation Findings: Root cause analysis and contributing factors identified

7. Environmental Conditions: Workplace conditions, weather, lighting, etc. at time of incident

8. Equipment/Materials Involved: Details of any equipment, tools, or materials involved in the incident

9. Corrective Actions: Recommended and implemented measures to prevent recurrence

10. Sign-off Section: Signatures of investigator, supervisor, and safety officer

Optional Sections

1. Medical Assessment: Details of medical evaluation and treatment, used when injury occurs

2. Property Damage Assessment: Evaluation of damage to equipment or facilities, used when property is affected

3. Environmental Impact: Assessment of environmental effects, used for incidents involving spills or emissions

4. Production Impact: Analysis of impact on operations and production, used for major incidents

5. Third Party Involvement: Details of external parties involved, used when contractors or visitors are affected

6. Legal Compliance Review: Assessment of regulatory compliance issues, used for serious incidents

Suggested Schedules

1. Photographic Evidence: Photos of incident scene, damage, or relevant conditions

2. Witness Statements: Detailed written accounts from witnesses

3. Medical Reports: Copies of medical assessments and treatment records

4. Equipment Inspection Reports: Technical evaluations of involved equipment

5. Site Diagrams: Sketches or plans showing incident location and relevant details

6. Training Records: Documentation of relevant training for involved personnel

7. Risk Assessment Forms: Pre-existing risk assessments related to the activity

8. Maintenance Records: Equipment maintenance history if relevant to the incident

Authors

Alex Denne

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

Relevant legal definitions







































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Relevant Industries

Manufacturing

Construction

Mining

Oil and Gas

Transportation

Logistics

Healthcare

Agriculture

Chemical Processing

Retail

Hospitality

Food Production

Automotive

Telecommunications

Utilities

Pharmaceutical

Warehousing

Education

Maritime

Aviation

Relevant Teams

Health and Safety

Human Resources

Operations

Quality Assurance

Risk Management

Facilities Management

Security

Emergency Response

Environmental Health

Production

Maintenance

Training

Compliance

Medical Services

Relevant Roles

Health and Safety Manager

Safety Officer

Department Supervisor

Plant Manager

HR Manager

Risk Management Officer

Operations Manager

Facility Manager

Site Supervisor

Quality Control Manager

Production Supervisor

Maintenance Manager

Environmental Health Officer

Compliance Officer

Security Manager

Line Supervisor

Training Coordinator

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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