JKKP 8 ( I ) /( IV )

Page..of..

Register of Accident, Dangerous Occurrence,

Occupational Poisoning and Occupational
Disease
Note: This form is required by Regulation 10 of the Occupational
Safety and Health (Notification of Accident, Dangerous Occurrence,
Occupational Poisoning and Disease) Regulation 2004 and must be
kept in the place of work for 5 years. Failure to maintain and post is
a contravention of the above.

Bil:

Employees Name & I/C or Passport

No.

Gender
M

For Calendar Year 20..

Industrial Classification
(Refer Table 3, insert code)

Size Industry #
Please tick ( / ) (Refer JKKP 8 (IV/IV)

Name of Employer / Self

Employers are required to maintain Employed:
a record of all accidents and
Name of Company:
diseases arising out of or in
connection with work which occur at Address:
the place of work.
Tel. No:
Age

Citizenship

Job Description
(Refer Table 8 )

Employment Status
(Refer Table 7 )

Date of
Incident

Time of
Incident

Nature of work
when incident
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

Bil:

Body
Location of
injury (Refer
Table 12 )
(1)

Type of
Accident
(Refer
Table 9 )
(2)

Outcome accident *
PD
(3)

NPD
(4)

Total
* PD : Permanent Disability
NPD : Non Permanent Disability
D
: Death

D
(5)

Accident with lost workdays

Type of injury

Enter number of
Accident without
Accident cases with
days away from
days away from work
lost workdays
work
(6)
(8)
(7)
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

________Yes

_________days

(Refer to
Table 10 )
(9)

Agent causing
injury
(Refer to
Table 11 )
(10)

_______Yes

Certification of Annual Register Totals by: .

Title: . Date:

Date of
submission
JKKP 6
(11)

JKKP 8 ( III ) /( IV )
OCCUPATIONAL POISONING AND DISEASE CASES

Bil.

Date of
Occupatio Location of
Poisoning /
nal
Disease
Poisoning
(Refer
/Disease Table 12 )
detected
(13)
(12)

Type of
Poisoning /
Disease
(Refer
Table 16 )
(14)

Route of
Entry
(Refer
Table 17 )
(15)

Agent
causing
Poisoning /
Disease
(Refer
Table 18 )
(16)

Total:

DANGEROUS OCCURRENCE

Poisoning / Disease with lost

workdays

Location
Type of
of
Fatalities Date of Dangerous Date of Time of
Poisoning /
Poisoning /
Enter
submissi Occurrence
incident
Disease
incident incident
Disease
number of
(death) on JKKP
(Refer
(Refer
cases with
days away without lost
(23)
(24)
Table 6 )
days away
Table
4)
7
(21)
workdays
from work
(22)
from work
(25)
(19)
(18)
(20)
(17)
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

No. days
not
operating
(26)

______Yes ____days ______Yes

Certification of Annual Register Totals by: .

Title: .

Date:.

Date of
submissio
n JKKP 6
(27)

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.
Leave this section blank if there were no Occupational Accident, Occupational Poisoning or Disease, please fill Y and Z only

OCCUPATIONAL ACCIDENT CASES

Accident related
fatalities (death)

Accident with lost

workdays

Total
man-hours
worked in Year 20..

OCCUPATIONAL POISONING AND DISEASE

Total of
Poisoning /
number of Disease related
accidents
fatalities

Accident without
lost workdays

Poisoning / Disease with

lost workdays

Total Poisoning /
Disease without lost
workdays

Y
(Round up to the
nearest whole number)

Number of
Deaths

Total
accident
cases with
days away
from work

Total
number of
days away
from work

Total accident
cases without
lost workdays

Enter the
Poisoning /
no. of days
Disease with
away from
lost workdays
work

Number of
Death

X
D

** Note: 1 day = 8 hours

No. of Fatalities (A) X 1000 =

Annual Average of No. Employees (Z)

Fatality Rate

Incident Rate

No. of Accidents (E) X 1000

=
Annual Average of No. Employees (Z)

Incident Rate =

Total workdays lost (C) X 1,000,000 =

Total man-hours worked (Y)

# Size Industry:
B : Annual Sales Turnover > RM 25 mil
M : Annual Sales Turnover = RM 10 - 25 mil
S : Annual Sales Turnover < RM 10 mil

OCCUPATIONAL POISONING AND DISEASE CASES

Fatality Rate

Frequency Rate = No. of Accidents (E) X 1,000,000

Total man-hours worked (Y)

(Round up to the
nearest whole number)

1 death = 6000 days (lost days)

OCCUPATIONAL ACCIDENT CASES

Severity Rate =

Total
average
employment in Year

Total number of
Poisoning / Disease
cases

(Workers > 151)

(Workers 51 - 150)
(Workers < 50)

No. of Fatalities (T) X 1000

Annual Average of No. Employees (Z)

No. Poisoning & Disease (X) X 1000

Annual average of No. Employees (Z)

Frequency Rate = No. of Poisoning & Disease (X) X 1,000,000

Total man-hours worked (Y)
Severity Rate =

Total workdays lost (V) X 1,000,000

Total man-hours worked (Y)

NAME

: ..

TITLE

: ..

SIGNATURE

: ..

DATE