SURAT KETERANGAN DOKTER

( Lampiran Bentuk III i )

DOCTOR’S CERTIFICATE
( Attachment form III i )

TENAGA YANG MENDAPAT KECELAKAAN TAMBANG KARENA HUBUNGAN KERJA

EMPLOYEE WHO GOT THE MINING ACCIDENT CAUSED BY WORKED RELATED

Pada Instalasi :
On Installation : Keri/Rawa Camp_PSC Oil Sumatra Onshore Ops
Dokter yang merawat harus melaporkan keadaan korban dalam 2 ( dua ) hari sesudah diperiksa
Doctor who taken cares have to report during two (days ) after examination

Nama Korban : Umur :

Name of Injured Person : Hipni Age : 38 years old
Jabatan : Cook_Andrawina PS Tgl dan waktu kecelakaan : Dec 19 ,2007 at 16.10 pm
Position : Date and time of accident :
Alamat : Palembang, Tempat kecelakaan :
Address : Place of accident : Kitchen _Keri/Rawa camp

Keterangan tentang luka-lukanya.

Sebutkan bagian badan yang cidera dengan
sifat lukanya( tunjukkan juga pada gambar ) : R L
Explanation about the wound R L
Mention the part of the body that injured and
wound Location (show at picture also) :
Minor cut wound (laceration) on right thumb
Cut avrg. 2 cm, no movement disability

Perawatan dan pengobatan.

Cara Perawatan dan pengobatan yang diberikan:
Nursing and Treatment
He way of nursing and treatment
Wound treatment
Betadine & sterile bandage
(No prescription medication)

Kehilangan hari kerja.

Akibat lukanya apakah yang bersangkutan diperlukan istirahat
untuk dapat melaksanakan kembali pekerjaannya. (Sebutkan
R L
kira-kira berapa hari).
Workday Lost
Due to the injury, should the victim take a rest then get back to
work (Name how many days approximately)
categorize as First Aid case
…………………………………………………. R L
…………………………………………………. R L R L
………………………………………………….

Uraian singkat terjadinya kecelakaan dengan sebab-sebabnya:

Short summary of accident and the root causes
The IP had slipped using knife when he is performing food
Preparation. No signs lack of conscious and he is not on any medication

Keterangan lain-lain:
Other :
No further complaint. The IP get back to work after treatment
………………………………………………….
Minor laceration (2 cm) on the right
point finger
Tanggal pemeriksaan :
Date of examination : Dec 21, 2007 > 08.30 am
Diperiksa oleh Paramedic :
Examined by : Dr. Wisnu Dharmawijaya.

Tanda tangan : OK……………………………………..

Signature : OK…………………………………………
Alamat :.
Address : Grissik Clinic, Medical PSC_ Corridor Block,
Sumatera Onshore Operations