Beruflich Dokumente
Kultur Dokumente
Page..1 of 1
For Calendar Year 2015
Register of Accident, Dangerous Occurrence, Industrial Classification
Occupational Poisoning and Occupational Disease
(Refer Table 3, insert code)
Size Industry # B
Please tick ( / ) (Refer JKKP 8 (IV/IV) B(/) M S
Name of Employer / Self
Employed:
Note: This form is required by Regulation 10 of the Occupational Employers are required to
Safety and Health (Notification of Accident, Dangerous Occurrence, maintain a record of all accidents Name of Company:
Occupational Poisoning and Disease) Regulation 2004 and must be and diseases arising out of or in Address:
kept in the place of work for 5 years. Failure to maintain and post is connection with work which occur
a contravention of the above. at the place of work.
Tel. No:
Gender Job Description Employment Status Time of Nature of work when incident
Bil: Age Citizenship (Refer Table 8) (Refer Table 7) Date of Incident Incident occurred
M F
# Size of industry
B : Annual Sales Turnover > RM 25 mil (Workers > 151) Certification of Annual Register Totals by :
M : Annual Sales Turnover = RM 10 - 25 mil (Workers 51 - 150) Title :
S : Annual Sales Turnover < RM 10 mil (Workers < 50)
JKKP 8 ( II ) /( IV )
OCCUPATIONAL ACCIDENT CASES
Outcome accident * Accident with lost workdays
Body Location Type of Agent causing Date of
of injury Accident Type of injury injury submission
Bil: Enter number of Accident without (Refer to (Refer
(Refer Table (Refer Table Accident cases with JKKP 6
PD NPD D days away from work
days away from lost workdays Table 10) (9) to Table 11)
12) (1) 9) (2) (3) (4) (5) work (10) (11)
(6) (8)
(7)
Total
* PD : Permanent Disability
NPD : Non Permanent Disability Certification of Annual Register Totals by:
D : Death Title:
JKKP 8 ( III ) /( IV )
OCCUPATIONAL POISONING AND DISEASE CASES DANGEROUS OCCURRENCE
Poisoning / Disease with lost
workdays
Date of Agent Fatalities
Location of Type of Location
Occupation Poisoning / Poisoning / Route of causing Type of
Poisoning / Date of of No. days Date of
al Entry Poisoning / Enter Poisoning / (death) submission Dangerous Date of Time of incident
Disease Disease Disease number not submissio
Bil. Poisoning / (Refer (Refer (Refer Disease of Disease JKKP 7 Occurrence incident incident (Refer operating n JKKP 6
Disease Table 17) (Refer cases with days away (Refer Table (23) (24)
days away from work without
Table 12) Table 16) lost (21) Table 4) (26) (27)
detected (13) (14) (15) Table 18) workdays 6) (22) (25)
(12) (16) from work (18) (19)
(17) (20)
Total:
Fatality Rate = No. of Fatalities (A) X 1000 = 0 Fatality Rate = No. of Fatalities (T) X 1000 = 0
Annual Average of No. Employees (Z) Annual Average of No. Employees (Z)
Incident Rate = No. of Accidents (E) X 1000 = Incident Rate = No. Poisoning & Disease (X) X 1000 = 0
0
Annual Average of No. Employees (Z) Annual average of No. Employees (Z)
Frequency Rate = No. of Accidents (E) X 1,000,000 = 0 Frequency Rate = No. of Poisoning & Disease (X) X 1,000,000 = 0
Total man-hours worked (Y) Total man-hours worked (Y)
Severity Rate = Total workdays lost (C) X 1,000,000 = Severity Rate = Total workdays lost (V) X 1,000,000 = 0
0
Total man-hours worked (Y) Total man-hours worked (Y)