Professional Documents
Culture Documents
Page 1 of………..
For Calendar Year 2010
Register of Accident, Dangerous Occurrence, Industrial Classification
Occupational Poisoning and Occupational (Refer Table 3, insert code) 2 4 2 2 1
Disease Size Industry #
Please tick ( / ) (Refer JKKP 8 (IV/IV)B M S
Name of Employer / Self
Note: This form is required by Regulation 10 of the Occupational Employers are required to maintain Employed:
Safety and Health (Notification of Accident, Dangerous a record of all accidents and Name of Company: Seamaster Paint (Manufacturing) Berhad
Occurrence, Occupational Poisoning and Disease) Regulation diseases arising out of or in
2004 and must be kept in the place of work for 5 years. Failure to connection with work which occur at Address: No 32 & 34,Jalan Firma 2/1,Tebrau Industrial Estate
maintain and post is a contravention of the above. 81100,Johor Bahru ,Johor
the place of work.
Tel. No: 07-3552088
Gender Nature of work
Employees Name & I/C or Job Description Employment Status Date of Time of
Bil: Age Citizenship when incident
Passport No. (Refer Table 8) (Refer Table 7) Incident Incident
M F occurred
1 KAMALRUAS YUDI B. GHAZALI / 30 MALAYSIA
# Size of industry
B : Annual Sales Turnover > RM 25 mil (Workers > 151) Certification of Annual Register Totals by : MOHD RAHIMI BIN HADADEK
M : Annual Sales Turnover = RM 10 - 25 mil (Workers 51 - 150) Title : Safety Officer Date : 22.01.11
S : Annual Sales Turnover < RM 10 mil (Workers < 50)
JKKP 8 ( II ) /( IV )
OCCUPATIONAL ACCIDENT CASES
* PD : Permanent Disability
NPD : Non Permanent Disability Certification of Annual Register Totals by: ……………………………………….
D : Death Title: ……….……………………………………… Date:……………………
JKKP 8 ( III ) /( IV )
OCCUPATIONAL POISONING AND DISEASE CASES DANGEROUS OCCURRENCE
Poisoning / Disease with lost
Date of workdays Location
Agent
Occupatio Location of Type of
causing
Type of
Fatalities Date of Dangerous of
Poisoning / Poisoning / Route of Date of
nal Poisoning / Poisoning /
Enter Poisoning / Date of Time of incident No. days
Disease Disease Entry (Refer Disease submissi Occurrence not submissio
Bil. Poisoning / (Refer (Refer Table 17)
Disease number of Disease (death) on JKKP (Refer
incident incident (Refer operating
(Refer cases with n JKKP 6
Disease Table 12) Table 16) (15) days away without lost (23) (24) Table 4)
Table 18) days away 7 (21) Table 6) (26) (27)
detected (13) (14) from work
from work workdays (22)
(12) (16) (18) (19) (25)
(17) (20)
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
Total: ______Yes ____days ______Yes
Fatality Rate = No. of Fatalities (A) X 1000 = Fatality Rate = No. of Fatalities (T) X 1000 =
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 =
Annual Average of No. Employees (Z) Annual average of No. Employees (Z)
Frequency Rate = No. of Accidents (E) X 1,000,000 = Frequency Rate = No. of Poisoning & Disease (X) X 1,000,000 =
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 =
Total man-hours worked (Y) Total man-hours worked (Y)
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 : ………………………………………………………………………