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JKKP 8 ( I ) /( IV )

Page…..of….
For Calender Year 20…..
Register of Accident, Dangerous Occurrence, Industrial Classification
Occupational Poisoning and Occupational Disease (Refer to Table 3, insert code) 2 7 2 0 9
Size of Industry #
Please tick ( / ) (Refer JKKP 8 IV/IV) B M S
Note: This form is required by Regulation 10 of the Name of employer/
Occupational Safety and Health (Notification of Employers are required to maintain a self employed:
Accident, Dangerous Occurrence, Occupational record of all accidents and diseases Name of Company:
Poisoning and Disease) Regulation 2004 and must arising out of or in connection with
Address:
be kept in the place of work for 5 years. Failure to work which occur at the place of
maintain and post is a contravention of the above work.
Regulation. Tel. No:
Gender Nature of work
Employees Name & I/C or Job Description (Refer Employment Status Date of Time of
No: Age Citizenship when incident
Passport No. Table 8) (Refer Table 7) incident incident
M F occurred

# 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: ……….……………………………………… Date:……………………
S - Annual sales turnover < RM 10 mil. (Workers 50)
JKKP 8 ( II ) /( IV )
OCCUPATIONAL ACCIDENT CASES

Body Location Type of Outcome accident * Accident with lost workdays Agent causing Date of
Accident Type of injury injury
of injury (Refer submission
No: (Refer to Accident cases Enter number Accident (Refer to (Refer to
Table 12) JKKP 6
Table 9) PD NPD D
with days away of days away without lost Table 10) (9) Table 11)
(1) (3) (4) (5) (10) (11)
(2) from work (6) from work (7) workdays (8)
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Total ______Yes _____days ______Yes

* PD : Permanent Disability
NPD : Non Permanent Disability Certification of Annual register totals by……………………………………….
D : Death Title: ……….……………………………………… Date:……………………
JKKP 8 ( III ) /( IV )
OCCUPATIONAL POISONING AND DISEASE CASES DANGEROUS OCCURRENCE

Date of Location Agent Poisoning/ Disease with lost workdays


Type of Route of Type of Location
Occupational of causing
Poisoning/ Entry Fatalities Date of Dangerous Date of Time of of No. days Date of
Poisoning/ Poisoning/ (Refer Poisoning/ Poisoning/ Enter Poisoning/ submission Occurrence incident not submission
No. Disease Disease (death) incident incident
Disease Disease (Refer to Table Disease number of Disease JKKP 7 (Refer operating JKKP 6
cases with (Refer to (23) (24)
(Refer to Table 16) (Refer to days away without lost (20) (27)
detected 17) days away (21) Table 6) Table 4) (26)
Table Table 18) from work workdays
(12) (14) (15) from work (22) (25)
12) (13) (16) (17) (18) (19)

Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Yes / No Yes / No
Total: ______Yes _____days _____Yes

Certification of Annual register totals by……………………………………….


Title: ……….……………………………………… Date:……………………
JKKP 8( IV / IV )
1. Occupational Accident and Occupational Poisoning / Disease Register (Covering Calendar Year 20…….)
● 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 POISONING AND DISEASE CASES
Total man-hours
Total Poisoning or
Total of Poisoning or worked in Year 20…..
Accident related Accident with lost Accident without Poisoning or disease disease without lost
number of disease related workdays Y
fatalities (death) workdays lost workdays with lost workdays
accidents fatalities
W (Round up to the
nearest whole number
Total Total number of
Total Poisoning Enter the Total average
accident Total accident Poisoning/ disease employment in Year
Number of number of Number of or disease no. of days
cases with cases without cases 20…..
deaths days away death with lost away from
days away lost workdays
from work workdays work X Z
from work
(Round up to the nearst
A B C D E T U V whole number)

** Note: 1 Day = 8 hours 1 death = 6000 days (lost days)

OCCUPATIONAL ACCIDENT CASES OCCUPATIONAL POISONING AND DISEASE CASES

Fatality Rate = No. of fatalities (A) X 1000 = Fatality Rate = No. of fatalities (T) X 1000 =
Annual average of No. employees (Z) Annual average of No. employees (Z)

Incident Rate = No. of accidents (E) X 1000 = Incident Rate = No. of poisoning & disease (X) X 1000 =
Annual average of No. employees (Z) Annual average of No. employees (Z)

Frequency Rate = No. of accidents (E) X 1,000,000 = Frequency Rate = No. of poisoning & disease (X) X 1,000,000 =
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 =
Total man-hours worked (Y) Total man-hours worked (Y)

# Size of industry: NAME:


B : Annual Sales turnover > RM 25 mil. ( Wokers > 151) TITLE:
M : Annual Sales turnover = RM 10 - 25 mil. ( Wokers 51 -150 )
S : Annual Sales turnover < RM 10 mil. ( Wokers < 50 ) SIGNATURE:
DATE: