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    JKKP 7

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    SwanBella
    This document is a report form for notifying authorities of occupational poisoning or disease. It requests information about the affected person such as their name, date of birth, occupation and diagnosis. It also requests details about the notifier, which can be the employer or attending medical practitioner. Finally, it asks for a description of the work that led to the occupational poisoning or disease, including any exposure to agents at the workplace. The purpose is to collect essential information about cases of occupational disease or poisoning to submit to the relevant safety and health authorities.

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    JKKP 7

    Uploaded by

    SwanBella
    348 views1 page
    This document is a report form for notifying authorities of occupational poisoning or disease. It requests information about the affected person such as their name, date of birth, occupation and diagnosis. It also requests details about the notifier, which can be the employer or attending medical practitioner. Finally, it asks for a description of the work that led to the occupational poisoning or disease, including any exposure to agents at the workplace. The purpose is to collect essential information about cases of occupational disease or poisoning to submit to the relevant safety and health authorities.

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    This document is a report form for notifying authorities of occupational poisoning or disease. It requests information about the affected person such as their name, date of birth, occupation and diagnosis. It also requests details about the notifier, which can be the employer or attending medical practitioner. Finally, it asks for a description of the work that led to the occupational poisoning or disease, including any exposure to agents at the workplace. The purpose is to collect essential information about cases of occupational disease or poisoning to submit to the relevant safety and health authorities.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    348 views1 page

    JKKP 7

    Uploaded by

    SwanBella
    This document is a report form for notifying authorities of occupational poisoning or disease. It requests information about the affected person such as their name, date of birth, occupation and diagnosis. It also requests details about the notifier, which can be the employer or attending medical practitioner. Finally, it asks for a description of the work that led to the occupational poisoning or disease, including any exposure to agents at the workplace. The purpose is to collect essential information about cases of occupational disease or poisoning to submit to the relevant safety and health authorities.

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    © All Rights Reserved
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    JKKP 7

    REPORT FOR OCCUPATIONAL POISONING / OCCUPATIONAL DISEASE OCCUPATIONAL SAFETY AND HEALTH
    (NOTIFICATION OF ACCIDENT, DANGEROUS OCCURANCE, OCCUPATIONAL POISONING AND OCCUPATIONAL DISEASE) REGULATION 2004

    Part A1 Part A2
    Notifier - Regulation 7(1) Employer Notifier - Regulation 7(2) Registered Medical Practitioner
    (If more than one person please use separate form)
    Name Name
    MR. HUSSEIN BIN HASSAN MR. FARID BIN AHMAD
    Designation Designation

    SAFETY & HEALTH OFFICER DOCTOR


    Name & Address of Organisation Address of Clinic / Hospital
    EXi HOLDING SDN BHD HOSPITAL BALIK PULAU,
    LOT 1357, JLN AU3, JALAN BALIK PULAU,
    KAWASAN PERINDUSTRIAN KECIL, 11000 BALIK PULAU,
    SERI RAJA, PENANG. PENANG.
    Contact Number Contact Number

    098501711 012-5634121
    R.O.C. No JKKP Reg. No NJK6569
    Industrial Classification Code (Table 3)
    Contact person (if different from above)

    Part B - Affected Person Part C - Occupational Poisoning / Disease

    Name Diagnosis / Provisional Diagnosis

    Date of Birth Date of Diagnosis

    NIRC/Passport No

    Nationality Gender L / P Name and Address of Attending Doctor

    Occupation
    Name & Addrress 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
    disease is thought to have been caused by exposure to an agent at work, e.g.a specific 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)

    Department of Occupational Safety and Health Ministry of Human Resources Malaysia 2005

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