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Occupational Health Incident Report

This document contains a notification form for reporting occupational poisoning or disease under Malaysian regulation. The form collects information about the notifier, affected person, diagnosis, and description of the work exposure. It requires the name, designation, and contact information of the employer and medical practitioner making the report, as well as demographic and medical details on the affected employee. Upon completion, the form disclaims any liability and provides a description of work exposure that may have led to the reported condition.

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Mohana Rajoo
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135 views1 page

Occupational Health Incident Report

This document contains a notification form for reporting occupational poisoning or disease under Malaysian regulation. The form collects information about the notifier, affected person, diagnosis, and description of the work exposure. It requires the name, designation, and contact information of the employer and medical practitioner making the report, as well as demographic and medical details on the affected employee. Upon completion, the form disclaims any liability and provides a description of work exposure that may have led to the reported condition.

Uploaded by

Mohana Rajoo
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

JKKP 7

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
Designation Designation
Name & Address of Organisation Address of Clinic / Hospital
Contact Number Contact Number
R.O.C. No J KKP Reg. No
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
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)
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)
REPORT FOR OCCUPATIONAL POISONING / OCCUPATIONAL DISEASE OCCUPATIONAL SAFETY AND HEALTH
(NOTIFICATION OF ACCIDENT, DANGEROUS OCCURANCE, OCCUPATIONAL POISONING AND OCCUPATIONAL DISEASE) REGULATION 2004
Department of Occupational Safety and Health Ministry of Human Resources Malaysia 2005

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