JKKP 8 ( I ) /( IV )

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For Calendar Year 2015
Register of Accident, Dangerous Occurrence, Industrial Classification
Occupational Poisoning and Occupational Disease
(Refer Table 3, insert code)
Size Industry # B
Please tick ( / ) (Refer JKKP 8 (IV/IV) B(/) M S
Name of Employer / Self
Employed:
Note: This form is required by Regulation 10 of the Occupational Employers are required to
Safety and Health (Notification of Accident, Dangerous Occurrence, maintain a record of all accidents Name of Company:
Occupational Poisoning and Disease) Regulation 2004 and must be and diseases arising out of or in Address:
kept in the place of work for 5 years. Failure to maintain and post is connection with work which occur
a contravention of the above. at the place of work.
Tel. No:
Gender Job Description Employment Status Time of Nature of work when incident
Bil: Age Citizenship (Refer Table 8) (Refer Table 7) Date of Incident Incident occurred
M F

# 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 :
S : Annual Sales Turnover < RM 10 mil (Workers < 50)
 JKKP 8 ( II ) /( IV )
OCCUPATIONAL ACCIDENT CASES
Outcome accident * Accident with lost workdays
Body Location Type of Agent causing Date of
of injury Accident Type of injury injury submission
Bil: Enter number of Accident without (Refer to (Refer
(Refer Table (Refer Table Accident cases with JKKP 6
PD NPD D days away from work
days away from lost workdays Table 10) (9) to Table 11)
12) (1) 9) (2) (3) (4) (5) work (10) (11)
(6) (8)
(7)

Total

* PD : Permanent Disability
NPD : Non Permanent Disability Certification of Annual Register Totals by:
D : Death Title:
 JKKP 8 ( III ) /( IV )
OCCUPATIONAL POISONING AND DISEASE CASES DANGEROUS OCCURRENCE
Poisoning / Disease with lost
workdays
Date of Agent Fatalities
Location of Type of Location
Occupation Poisoning / Poisoning / Route of causing Type of
Poisoning / Date of of No. days Date of
al Entry Poisoning / Enter Poisoning / (death) submission Dangerous Date of Time of incident
Disease Disease Disease number not submissio
Bil. Poisoning / (Refer (Refer (Refer Disease of Disease JKKP 7 Occurrence incident incident (Refer operating n JKKP 6
Disease Table 17) (Refer cases with days away (Refer Table (23) (24)
days away from work without
Table 12) Table 16) lost (21) Table 4) (26) (27)
detected (13) (14) (15) Table 18) workdays 6) (22) (25)
(12) (16) from work (18) (19)
(17) (20)

Total:

Certification of Annual Register Totals by:

Title:
 JKKP 8( IV / IV )
1. Occupational Accident and Occupational Poisoning / Disease Register (Covering Calendar Year 2015)
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 OCCUPATIONAL POISONING AND DISEASE Total man-hours worked in
Year 2015
Total Poisoning / Y (0)
Accident related Accident with lost Accident Total of Poisoning / Poisoning / Disease with Disease without lost
without lost number of Disease related workdays
fatalities (death) workdays workdays accidents fatalities lost workdays (Round up to the nearest
W (0) whole number)
Total average employment in
Total Total number of Year 2015
Total Enter the Poisoning / Disease
accident Total accident Poisoning /
Number of cases with number of cases without Number of Disease with no. of days cases
Deaths days away Death away from Z (0)
days away lost workdays lost workdays
from work from work work
X (0)
(Round up to the nearest
whole number)
A (0) B (0) C (0) D (0) E (0) T (0) U (0) V (0)

** 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 = 0 Fatality Rate = No. of Fatalities (T) X 1000 = 0
Annual Average of No. Employees (Z) Annual Average of No. Employees (Z)

Incident Rate = No. of Accidents (E) X 1000 = Incident Rate = No. Poisoning & Disease (X) X 1000 = 0
0
Annual Average of No. Employees (Z) Annual average of No. Employees (Z)

Frequency Rate = No. of Accidents (E) X 1,000,000 = 0 Frequency Rate = No. of Poisoning & Disease (X) X 1,000,000 = 0
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 = 0
0
Total man-hours worked (Y) Total man-hours worked (Y)

# Size Industry: NAME :

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