Beruflich Dokumente
Kultur Dokumente
Part A1
Notifier - Regulation 7(1) Employer
Name
Designation
Name & Address of Organisation
Contact number
0
R.O.C. No.
JKKP Reg. No.
123456
0
Gender
Occupation
Name & Address of Organisation
Location of incident
Part D
Description of work that led to occupational poisoning/disease (Please describe any work done by the affected person which might have led to them getting the
chemical - please state what that agent is.)
Signature of Notifier
Date
Disclaimer
Completing this form does not constitute to an admission of liability of any kind by the person making the report or by any other person(s).
Part A2
Notifier - Regulation 7(2) Registered Medical Practitioner
Name
Designation
Address of Clinic/Hospital
Contact number
hich might have led to them getting the disease. If the disease is thought to have been caused by exposure to an agent at work, e.g. a specific
Industrial Classification
(Refer to Table 3, insert code)
Size of Industry #
Please tick ( / ) (Refer JKKP 8 IV/IV)
Name of Company:
Address :
Tel. No. :
No:
Employees
Name
I/C or
Passport No.
# Size of industry.
B : Annual sales turnover > RM 25 mil. (Workers > 151)
M : Annual sales turnover = RM 10 - 25 mil. (Workers 51 - 150)
S - Annual sales turnover < RM 10 mil. (Workers 50)
Gender
M
Age
Citizenship
Job Description
(Refer Table 8)
Certific
Title :
JKKP 8 ( I ) /( IV )
Page 1 of 2
strial Classification
of Industry #
e of Company:
Employment
Status (Refer
Table 7)
Date of incident
Time of
incident
No.
Body Location
Type of
of injury (Refer Accident
Table 12)
(Refer to Table
(1)
9)
(2) PD
* PD : Permanent Disability
NPD : Non-permanent Disability
D
: Death
(3) NPD
Accident cases
with days away
from work
(5)
(6)
(4) D
0
Certification of Annual register
Title :
JKKP 8 ( II ) /( IV )
CCIDENT CASES
Accident with lost workdays
Enter number of
Accident
days away from without lost
work
workdays
(7)
(8)
Date of
Agent causing
submission
Type of injury
injury
(Refer to Table (Refer to Table JKKP 6
(11)
10)
(9)
11)
(10)
Date of
Location of
Type of
Agent causing
Poisoning/ Disease with lost workd
Occupational
Poisoning/
Poisoning/
Poisoning/
Poisoning/
Poisoning/
Disease
Disease
Route of Entry
Disease
Disease cases
Disease
(Refer to
(Refer to
(Refer Table 17) (Refer to
with days away
detected (12) Table 12) (13) Table 16) (14)
(15)
Table 18) (16) from work (17)
D DISEASE CASES
DANGEROUS OCCURRENCE
Poisoning/
Disease without
lost workdays
(19)
Fatalities /
Death (20)
Date of
submission
JKKP 7
(21)
Type of
Dangerous
Occurrence
Location of
(Refer to Table Date of incident Time of incident incident (Refer
6)
(22)
(23)
(24)
Table 4) (25)
Date :
JKKP 8 ( III ) /( IV )
CCURRENCE
No. days not
operating
(26)
Date of
submission
JKKP 6
(27)
1. Occupational Accident and Occupational Poisoning / Disease Register (Covering Calendar Year 2009)
Complete this section by copying totals from the annual register.
If there were no Occupational accident, Occupational poisoning or disease, please fill section Y & Z only
OCCUPATIONAL ACCIDENT CASES
OCCUPATIONAL POISO
Accident
related
fatalities
(death)
Number of
deaths
Accident
without lost
workdays
Total of
number of
accidents
Total accident
Total number Total accident
cases with
of days away cases without
days away
from work lost workdays
from work
Number of death
0.0
0.0
0.0
0.0
Fatality Rate =
No. of fatalities (
Incident Rate =
No. of poisoning
Severity Rate
NAME :
# Size of industry:
B : Annual Sales turnover
> RM 25 mil.
= RM 10 - 25 mil.
( Wokers 51 -150 )
< RM 10 mil.
( Wokers < 50 )
TITLE :
SIGNATURE :
DATE :
= Total workdays lo
JKKP 8( IV / IV )
320
(Round up to the nearest whole number)
823,866
(Round up to the nearst whole number)
atality Rate =
0.0
cident Rate =
everity Rate
TLE :
IGNATURE :
0.0
0.0
0.0
JK6655
3. Name of Organisation
4. Address of Organisation
PLO 1234, Jln Industri 5/2, Tmn Industri Tampoi, Johor Bahru,
5. Postcode
81100
7. R.O.C. Number
123456
9. Industrial Classification
3454
6. Size of Industry
8. Date of Submission of JKKP 6
(Refer Table 3)
The
(Refer Table 4)
07-5427232
(Refer Table 6)
5. Sex (M/F)
6. Status of Employment
(Refer Table 7)
8. Job Description
(Refer Table 8)
9. Race
10. Nationality
11. No.of Safety and Health Training Attended
12. Type of Accident
(Refer Table 9)
16. No. of Days The Victim Doing Same Task Before Accident
17. Outcome of Accident
18. Lost Time Injury (Days)
INVESTIGATION INFORMATION
1. Investigator (1)
2. Investigator (2)
3. Action Taken
NOP
NOI
PLS
PL
SEALED
7. Date of Report
8. Investigator's Comment Including The Basic and Immediate Cause of Accident
IDENT
ALTH
OCCURRENCE,
EASE) REGULATIONS 2004
(Refer Table 1)
ssion of JKKP 6
2. Time of Occurrence
4. No. of Victim
(Refer Table 5)
(Refer Table 6)
IDENT
Work
IDENT
DIRECTIVE
er Investigations
COMPOUND
COURT
JKKP 10
JK6655
3. NAME OF ORGANISATION
4. ADDRESS OF ORGANISATION
5. POSTCODE
7. ROC NUMBER
123456
8. DATE OF SUBMISSION JK
3454
16 SHIFT WORK
(1 day is equivalent to
5. ROUTE OF ENTRY?
(Refer Table 17)
6. MECHANISM OF POISONING/ DISEASE
(Refer Table 18)
7. AGENT OF POISONING/ DISEASE
8. IMMEDIATE CAUSE
( Refer Table 13)
KKP 10
Medium
12. TIME:
14. NO. OF VICTIM
ILITY
TELEPHONE NO.
JKKP 10
IENT'S DATA
5. SEX (M/F)
7. DATE OF BIRTH
10. MARITAL STATUS
JKKP 10