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JKKP 7 - REPORT FOR OCCUPATIONAL POISONING /

OCCUPATIONAL SAFETY AND HEALTH (NOTIFICATION OF ACCIDENT, DANGEROUS OCCURRENCE, OCCUP

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

Industrial Classification Code (Table 3)

Contact person (If different from above)

Part B - Affected Person


Name
Date of Birth
NRIC/Passport No.
Nationality

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).

ATIONAL POISONING / OCCUPATIONAL DISEASE

OUS OCCURRENCE, OCCUPATIONAL POISONING AND OCCUPATIONAL DISEASE) REGULATION 2004

Part A2
Notifier - Regulation 7(2) Registered Medical Practitioner
Name
Designation
Address of Clinic/Hospital

Contact number

Part C - Occupational Poisoning/Disease


Diagnosis/Provisional Diagnosis
Date of Diagnosis
Name & Address of Attending Doctor

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

Register of Accident, Dangerous


Occurrence, Occupational Poisoning
and Occupational Disease

Industrial Classification
(Refer to Table 3, insert code)

Size of Industry #
Please tick ( / ) (Refer JKKP 8 IV/IV)

Name of employer / self employ


Note: This form is required by Regulation 10 of the Occupational
Safety and Health (Notification of Accident, Dangerous
Occurrence, Occupational Poisoning and Disease) Regulation
2004 and must be kept in the place of work for 5 years. Failure to
maintain and post is a contravention of the above Regulation.

Employers are required to maintain a record of all


accidents and diseases arising out of or in connection
with work which occur at the place of work.

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

r to Table 3, insert code)

of Industry #

e tick ( / ) (Refer JKKP 8 IV/IV)

For Calender Year


S

e of employer / self employed :

e of Company:

Employment
Status (Refer
Table 7)

Date of incident

Time of
incident

Nature of work when incident


occurred

Certification of Annual register totals by :


Date :

OCCUPATIONAL ACCIDENT CASES


Outcome accident *

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 with lost workdays

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)

Certification of Annual register totals by :


Date :

OCCUPATIONAL POISONING AND DISEASE CASES


No.

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 with lost workdays


Enter number of
days away from
work (18)

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)

Certification of Annual register totals by :


Title :

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 with lost workdays

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

Poisoning or disease related


fatalities

Number of death

** Note: 1 Day = 8 hours

1 death = 6000 days (lost days)

OCCUPATIONAL ACCIDENT CASES


Fatality Rate =

No. of fatalities (A) X 1000

Annual average of No. employees (Z)


Incident Rate =

No. of accidents (E) X 1000

Annual average of No. employees (Z)


Frequency Rate = No. of accidents (E) X 1,000,000

Total man-hours worked (Y)


Severity Rate

= Total workdays lost (C) X 1,000,000 =


Total man-hours worked (Y)

0.0

0.0

0.0

0.0

Fatality Rate =

No. of fatalities (

Incident Rate =

No. of poisoning

Frequency Rate = No. of poisoning

Severity Rate

NAME :

# Size of industry:
B : Annual Sales turnover

> RM 25 mil.

( Wokers > 151)

M : Annual Sales turnover

= RM 10 - 25 mil.

( Wokers 51 -150 )

S : Annual Sales turnover

< RM 10 mil.

( Wokers < 50 )

TITLE :
SIGNATURE :
DATE :

= Total workdays lo

JKKP 8( IV / IV )

Covering Calendar Year 2009)

e, please fill section Y & Z only


OCCUPATIONAL POISONING & DISEASE CASES
Poisoning or disease with
lost workdays

Total man-hours worked in Year 2009

Total Poisoning or disease without lost


workdays

320
(Round up to the nearest whole number)

Poisoning or Enter the no.


disease with of days away
lost workdays from work

Total number of Poisoning/ disease cases

Total average employment in Year 2009

823,866
(Round up to the nearst whole number)

days (lost days)


OCCUPATIONAL POISONING AND DISEASE CASES

atality Rate =

No. of fatalities (T) X 1000

0.0

Annual average of No. employees (Z)

cident Rate =

No. of poisoning & disease (X) X 1000

Annual average of No. employees (Z)

equency Rate = No. of poisoning & disease (X) X 1,000,000 =

everity Rate

TLE :

IGNATURE :

Total man-hours worked (Y)


= Total workdays lost (V) X 1,000,000
Total man-hours worked (Y)

0.0

0.0

0.0

JKKP 9 - INFORMATION ON ACCIDENT


OCCUPATIONAL SAFETY AND HEALTH
(NOTIFICATION OF ACCIDENT, DANGEROUS OCCURRENCE,
OCCUPATIONAL POISONING AND OCCUPATIONAL DISEASE) REGULATIONS 2004
DATA F O R AC C I D E N T
1. JKKP Reg. No.

JK6655

3. Name of Organisation

2. Case Ref. No.


XYZ Mfg Industries (M) Sdn Bhd

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

10. Name and Address Where


Accident Occurred

6. Size of Industry
8. Date of Submission of JKKP 6
(Refer Table 3)

The

11. Date of Accident

12. Time of Occurrence

13. Area of Accident


15. No. of
Fatalities

(Refer Table 4)

16. No. of Permanent Disability

17. No. of Non Permanent Disabili

18. Brief Report of The Accident

19. Responsible Person (Construction Site Only)


20. If Self Employed, Is The Victim a Member of The Family (Y/N)
21. Name of Notifier
22. Designation
23. Telephone No.
24. Type of Report

14. No. of Victim

07-5427232

25. If Dangerous Occurrence Enter The Code

(Refer Table 6)

JKKP 9 - INFORMATION ON ACCIDENT


D E TAI LS O F V I C T I M
1. Name of Victim
2. I/C No. / Passport No.
3. Address of Victim
4. Age

5. Sex (M/F)

6. Status of Employment

(Refer Table 7)

7. Date of Start Work

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)

13. Type of Injury

(Refer Table 10)

14. Agent Causing Accident

(Refer Table 11)

15. Location of Injury

(Refer Table 12)

16. No. of Days The Victim Doing Same Task Before Accident
17. Outcome of Accident
18. Lost Time Injury (Days)

JKKP 9 - INFORMATION ON ACCIDENT


[This page is for DOSH use only)

INVESTIGATION INFORMATION
1. Investigator (1)
2. Investigator (2)
3. Action Taken

NOP

NOI

PLS

PL

SEALED

4. Date of Accident Reported


5. Date of Investigation

6. Date of Further Investigations

7. Date of Report
8. Investigator's Comment Including The Basic and Immediate Cause of Accident

9. Comments by Unit Head

10. Comments by Director

IDENT

ALTH
OCCURRENCE,
EASE) REGULATIONS 2004

ndustries (M) Sdn Bhd

mn Industri Tampoi, Johor Bahru, Johor


Medium

(Refer Table 1)

ssion of JKKP 6

2. Time of Occurrence

4. No. of Victim

7. No. of Non Permanent Disability

(Refer Table 5)

(Refer Table 6)

IDENT

Work

IDENT

DIRECTIVE

er Investigations

COMPOUND

COURT

JKKP 10

DEPARTMENT OF OCCUPATIONAL SAFETY AND HEA


NOTIFICATION OF ACCIDENT, DANGEROUS OCCURR
OCCUPATIONAL POISONING AND OCCUPATIONAL DIS

DATA FOR OCCUPATIONAL POISONING AND OCCUPATIONA


1. JKKP REG. NO.

JK6655

3. NAME OF ORGANISATION

XYZ Mfg Indus

4. ADDRESS OF ORGANISATION
5. POSTCODE
7. ROC NUMBER

PLO 1234, Jln Industri 5/2, Tmn


81100

6. SIZE OF INDUSTRY (Refer Ta

123456

8. DATE OF SUBMISSION JK

9. INDUSTRIAL CLASSIFICATION (Refer Table 3)

3454

10. NAME & ADDRESS WHERE DISEASES & POISONING OCCURRED


11. DATE OF DISEASE DETECTED
13. AREA OF OCCURRENCE (Refer Table 4)
15. NO. OF FATALITIES

16. PERMANENT DISABILITY

18. BRIEF REPORT ON THE POISONING AND DISEASE

19. IF SELF-EMPLOYED, IS THE PATIENT A MEMBER OF THE FAMILY? (Y/N)


20. NAME OF NOTIFIER
21. DESIGNATION

DEPARTMENT OF OCCUPATIONAL SAFETY AND H


PATIENT'S INFORMATION FORM FOR INDUSTRIAL DISEASE
PATIENT'S DATA
1. I/C NO./ PASSPORT NO.
2. NAME OF PATIENT
3. ADDRESS
4. AGE
6. STATUS OF EMPLOYMENT
(Refer Table 7)
8. RACE
9. NATIONALITY
11. PREVIOUS JOB HISTORY
Company's Name :
Job Description :
Length of Services :
Hazards Identified :
PPE Used :

NOTES : IMPORTANT DATA REQUIRED ARE NAME OF PREMIS, JOB DES

LENGTH OF SERVICE, HAZARD IDENTIFIED AND P.P.E U

CURRENT JOB STATUS

12. EMPLOYMENT DATE

13. JOB DESCRIPTION


(Refer Table 8)

14. TYPE OF HAZARDS


(Refer Table 15)
15. PPE USED
16 SHIFT WORK

17. TOTAL WORKING

16 SHIFT WORK

(1 day is equivalent to

DEPARTMENT OF OCCUPATIONAL SAFETY AND H


PATIENT'S INFORMATION FORM FOR INDUSTRIAL DISEASE

DATA FOR INDUSTRIAL DISEASE AND POISON


1. TYPES OF POISONING/DIESEASES
(Refer Table 16)
2. LOCATION OF AFFECTED PART?
(Refer Table 12)

3. WHAT WAS THE PATIENT'S ACTIVITY DURING THE INCIDENT?

4. WHAT WAS THE SYMPTOM ON THE WORKERS ?

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)

9. TYPES OF HAZARD MONITORING CONDUCTED AND WHAT ARE


THE RESULTS?

10. WAS RISK ANALYSIS TO THE WORKERS' HEALTH CONDUCTED?

11. REMARK ON THE RESULTS

12. WAS HEALTH SURVEILLANCE PROGRAMME CONDUCTED ON THE WORKERS?

13. REMARKS ON BIOLOGICAL MONITORING, PRE MEDICAL EXAMINATION AND


MEDICAL SURVEILLANCE
14. IMPLICATION FROM THE POISONING / DISEASE ?
(Refer Table 19)
15. NO. OF LOST WORKING DAYS
16. WHAT WAS THE PREVENTION STEPS TAKEN BY THE EMPLOYER

KKP 10

UPATIONAL SAFETY AND HEALTH


ENT, DANGEROUS OCCURRENCE,
NG AND OCCUPATIONAL DISEASES

SONING AND OCCUPATIONAL DISEASE


2. COMPANY'S REF. NO.
XYZ Mfg Industries (M) Sdn Bhd
PLO 1234, Jln Industri 5/2, Tmn Industri Tampoi, Johor Bahru, Johor
6. SIZE OF INDUSTRY (Refer Table 1)

Medium

8. DATE OF SUBMISSION JKKP7


3454

12. TIME:
14. NO. OF VICTIM

ILITY

THE POISONING AND DISEASES

17. NON PERMANENT DISABILITY

TELEPHONE NO.

JKKP 10

PATIONAL SAFETY AND HEALTH


OR INDUSTRIAL DISEASE AND POISONING

IENT'S DATA

5. SEX (M/F)
7. DATE OF BIRTH
10. MARITAL STATUS

OUS JOB HISTORY

ED ARE NAME OF PREMIS, JOB DESCRIPTION,

E, HAZARD IDENTIFIED AND P.P.E USED

ENT JOB STATUS


13. JOB DESCRIPTION
(Refer Table 8)

17. TOTAL WORKING HOURS

(1 day is equivalent to 8hours)

PATIONAL SAFETY AND HEALTH


OR INDUSTRIAL DISEASE AND POISONING

AL DISEASE AND POISONING

JKKP 10