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Borang jkkp9

This 3 sentence summary provides the key details about the document: The document appears to be a form collecting information on workplace accidents for reporting purposes, as it requests details about the accident, the victim, the employer, and includes sections for investigation information and comments. The form collects various data points to characterize the accident such as the date, location, injuries sustained, potential causes, and outcome, as well as information about the victim like their job and safety training history. The level of detail requested suggests the goal is to thoroughly document accidents to facilitate investigation and prevention of future incidents.

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ainur
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836 views3 pages

Borang jkkp9

This 3 sentence summary provides the key details about the document: The document appears to be a form collecting information on workplace accidents for reporting purposes, as it requests details about the accident, the victim, the employer, and includes sections for investigation information and comments. The form collects various data points to characterize the accident such as the date, location, injuries sustained, potential causes, and outcome, as well as information about the victim like their job and safety training history. The level of detail requested suggests the goal is to thoroughly document accidents to facilitate investigation and prevention of future incidents.

Uploaded by

ainur
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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JKKP 9

INFORMATION ON ACCIDENT
OCCUPATIONAL SAFETY AND HEALTH (NOTIFICATION OF ACCIDENT, DANGEROUS OCCURRENCE,
OCCUPATIONAL POISOINING AND OCCUPATIONAL DISEASE) REGULATIONS 2004

DATA FOR ACCIDENT

1. JKKP Reg. No. 2. Case Ref No.

3. Name of Organisation

4. Address of Organisation

5. Postcode 6. Size of Industry ( Refer Table l 1)

7. R.O.C. Number 8. Date of Submission of JKKP 6

9. Industrial Classification ( Refer Table 3)

10. Name and Address


Where The Accident
Occurred

11. Date of Accident 12. No. of Permanent

13. Area of Accident ( Refer Table 4) 14. No. of Victim

15. No. of 16. No. of Permanent 17. No. of Non Permanent

Fatalities Disability Disability

18. Brief Report of The Accident

19. Responsible Person (Construction Site Only) ( Refer Table 5)

20. If Self Employed, Is The Victim a Member of The Family Yes No

21. Name of Notifier

22. Designation

23. Telephone No.

24. Type of Report Accident Dangerous Occurrence

25. If Dangerous Occurrence Enter The Code (Refer Table 6)


JKKP 9
INFORMATION ON ACCIDENT

INFORMATION ON ACCIDENT

1. Name of Victim

2. I/C No. / Passport No.

3. Address of Victim

4. Age 5. Gender Male Female

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 )

Agent Causing
14. (Refer Table 11 )
Accident

15. Location of Injury (Refer Table 12 )

16. No. of Days The Victim Doing Same Task Before Accident

Permanent Without Permanent


Fatality
17. Outcome of Accident Disability Disability

18. Lost Time Injury


(Days)
JKKP 9
INFORMATION OF ACCIDENT

[This page is for DOSH Use only]

INVESTIGATION INFORMATION

1. Investigator (1)

2. Investigator (2)

3. Action Taken NOP NOI PLS PL Sealed Directive Compound Court

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

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