Formulir Pelaporan Kejadian Tertusuk Jarum

RUMAH SAKIT  Jl. Lintas Sumatera Sumatera No.12 Kalibalangan-Lampun Kalibalangan-Lampung g Utara,  Telp  Telp :(072! :(072! "2#02", $mail $mail : rs.%m&2011'gmail.om SITU No : 503.7.2/15-04/37-LU/2011 IMB No : 503/054-04/37-LU/2011

Formulir Pelaporan Kejadian Tertusuk Jarum I.

II. II.

IDENTITAS

 Nama

:

Unit Kerja

:

Rinc Rincia ian n Kej Kejad adia ian n 1. Tanggal dan waktu insiden Tanggal : Jam :

2. Insiden Luka tusukan tusukan jarum suntik  o Luka iris o Percikan pada mukosa idung! mulut atau kulit o Percikan pada mata o ". Kronologi Insiden .................................................................................................................................. .................................................................................................................................. .................................................................................................................................. ...................................... #. Tindakan $ang dilakukan setela kejadian .................................................................................................................................. .................................................................................................................................. .................................................................................................................................. ......................................

Penerima Laporan

Pemuat Laporan

Para%

Para%  

Tanggal Lapor

Tanggal Lapor  

RUMAH SAKIT  Jl. Lintas Sumatera No.12 Kalibalangan-Lampung Utara,  Telp :(072! "2#02", $mail : rs.%m&2011'gmail.om SITU No : 503.7.2/15-04/37-LU/2011 IMB No : 503/054-04/37-LU/2011