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Data For Accident: (Refer Table 3)

This document contains forms for reporting workplace accidents, dangerous occurrences, and occupational diseases in Malaysia. The forms collect information about the employer, location of the incident, victim details, investigation details, and analysis of the root causes. It includes tables to standardize responses for things like industry type, area of accident, victim job and injury details. The purpose is to document incidents for investigation and prevention of future safety issues.

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105 views

Data For Accident: (Refer Table 3)

This document contains forms for reporting workplace accidents, dangerous occurrences, and occupational diseases in Malaysia. The forms collect information about the employer, location of the incident, victim details, investigation details, and analysis of the root causes. It includes tables to standardize responses for things like industry type, area of accident, victim job and injury details. The purpose is to document incidents for investigation and prevention of future safety issues.

Uploaded by

amin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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OCCUPATIONAL SAFETY AND HEALTH ACT 1994 (ACT 514)

NOTIFICATION OF ACCIDENT, DANGEROUS OCCURRENCE,


OCCUPATIONAL POISONING AND OCCUPATIONAL DISEASES

JKKP 9

DATA FOR ACCIDENT


1. JKKP REG. NO 2. COMPANY'S REF. NO.

3. NAME OF ORGANISATION

4. ADDRESS OF
ORGANISATION

5. POSTCODE 6. SIZE OF INDUSTRY (Refer Table 1)

8. DATE OF SUBMISSION OF
7. ROC NUMBER
JKKP6
9. INDUSTRIAL CLASSIFICATION (Refer Table 3)

10. NAME AND ADDRESS


WHERE THE ACCIDENT
OCCURRED

11. DATE OF ACCIDENT 12. TIME OF OCCURRENCE


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 ACCIDENTS

19. RESPONSIBLE PERSON (CONSTRUCTION SITE ONLY) (Refer Table 5)

20. IF SELF EMPLOYED, DOES THE VICTIM PART OF THE FAMILY (Y/N)

21. NAME OF NOTIFIER

22. DESIGNATION

23. TELEPHONE NO.

24. TYPES OF REPORT ACCIDENT / DANGEROUS OCCURRENCE


25. IF DANGEROUS OCCURRENCE ENTER THE CODE (Refer Table 6)
DEPARTMENT OCCUPATIONAL SAFETY AND HEALTH

INFORMATION OF VICTIM JKKP 9

DETAILS OF VICTIM

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. AGENCY CAUSING ACCIDENT (Refer Table 11)

15. LOCATION OF INJURY (Refer Table 12)

16. NO. OF DAYS ON THE VICTIM DOING SAME TASK BEFORE ACCIDENT

17. OUTCOME OF ACCIDENT FATALITY / PERMANENT DISABLITY / WITHOUT PERMANENT DISABLITY

18. LOST TIME INJURY (DAYS)


JKKP 9

INVESTIGATION IMFORMATION

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 INLUDING THE BASIC AND IMMEDIATE CAUSE OF ACCIDENT

9. COMMENTS BY UNIT HEAD

10. COMMENTS BY DIRECTOR

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