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.
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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
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
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
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