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Drill Plan Form

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EMERGENCY

(AREA , DEPARTMENT )

DRILL REPORT
(NAME OF DRILL)
EMERGENCY DRILL REPORT
DATE: TIME:

NAME OF DRILL:

DEPARTMENT:

1. OBJECTIVE DRILL / TUJUAN DRILL

2. TARGET / TARGET

3. DATE / TANGGAL

4. LOCATION / LOKASI

5. DRILL COMMITTEE / KOMITE DRILL

a. Exercise Director :

b. Head Assessor:

c. Head Controller:

d. Safety Officer:

e. Rescue Officer:

6. SCENARIO DETAIL / RINCIAN SKENARIO


EMERGENCY DRILL REPORT
DATE: TIME:

NAME OF DRILL:

DEPARTMENT:

7. SAFETY CONSIDERATION / PERTIMBANGAN KESELAMATAN

RISK DETAIL RISK RISK CONTROL

(POTENTIAL RISK AND LOCATION)

8. DRILL FINDING / TEMUAN LATIHAN

COMPLY
ITEM FACT FINDING
(YES/NOT)
RESPONSE TIME

COMMUNICATION

PROCEDURE

OPERATION

PROCEDURE

RESPONSE

PROCEDURE

SAFETY ASPECT

SECURITY ASPECT
EMERGENCY DRILL REPORT
DATE: TIME:

NAME OF DRILL:

DEPARTMENT:

FACILITY ASPECT

OTHER

9. IMPROVEMENT ACTION PLAN / RENCANA TINDAKAN PERBAIKAN

FINDING IMPROVEMENT ACTION PLAN WHEN WHO


RESPONSE TIME

COMMUNICATION

PROCEDURE

OPERATION

PROCEDURE

RESPONSE

PROCEDURE

SAFETY ASPECT

SECURITY ASPECT

FACILITY ASPECT

OTHER

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