JKKP 8 ( I ) /( IV )

Page …….. of ….….

For Calender Year 20
Register of Accident, Dangerous Occurrence, Industrial Classification
Occupational Poising and Occupational Diseace
(Refer to Table 3,insert code)
Size of Industry #
Please tick ( / ) (Refer JKKP 8 (IV/IV) B B S M K S
Name of employer/
self employer :
Note: This form is required by Regulation 10 of the
Employers are required to maintain
Occupational Safety and Health (Notification of Accident, Name of Company :
a record of all accidents and
Dangerous Occurrence, Occupational Poisoning and
diseases arising out of or in Address :
Disease) Regulation 2004 and must be kept in the place
connection with work which occur at
of work for 5 years. Failure to maintain and post is a
the place of work..
contravention of the above.

Tel. No :
Employment Nature of work
Employees Name & I/C or Gender Job Description Date of Time of
No: Age Citizenship Status (Refer when incident
Passport No. (Refer Table 8 ) incident incident
M F Table 7 ) 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 - RM 25 mil. (Workes 51 - 150) Title :……………………………………………………………………………….

S : Annual sales turnover < RM 10 mil. (Workers< 50) Date : …………………………………………..
 JKKP 8 ( II ) /( IV )
OCCUPATIONAL ACCIDENT CASES
Outcome accident * Accident with lost workdays
Body Type of Agent causing
Type of Date
Location of Accident injury
Accident cases with Enter number injury (Refer submission
No: injury (Refer (Refer Accident without (Refer
PD NPD D days away from of days away Table 10 ) JKKP 6
Table 12 ) Table 9 ) lost workdays (8) Table 11 )
(3) (4) (5) work (6) from work (9) (11)
(1) (2) ( Yes / No ) (10)
(Yes/ No) (7)

* PD : Permanent Disability Certification of Annual register totals by

NPD : Non Permanent Disability
D : Death Title:

Date:
 JKKP 8 ( II ) /( IV )
OCCUPATIONAL ACCIDENT CASES
Outcome accident * Accident with lost workdays
Body Type of Agent causing
Type of Date
Location of Accident injury
Accident cases with Enter number injury (Refer submission
No: injury (Refer (Refer Accident without (Refer
PD NPD D days away from of days away Table 10 ) JKKP 6
Table 12 ) Table 9 ) lost workdays (8) Table 11 )
(3) (4) (5) work (6) from work (9) (11)
(1) (2) ( Yes / No ) (10)
(Yes/ No) (7)

Total ________Yes _____days _______Yes

* PD : Permanent Disability Certification of Annual register totals by

NPD : Non Permanent Disability
D : Death Title:

Date:
 JKKP 8 ( III ) /( IV )
OCCUPATIONAL POISING AND DISEASE CASES DANGEROUS OCCURRENCE
Poisoning/ Disease with lost
Date of Agent workdays Location
Location of Type of Route Type of
causing Date of of Date of
Occupational Poisoning/ Poisoning/ of Entry Poisoning/ Poisoning/ Dangerous No. days
Poisoning/ Disease Enter Fatalities Date of Time of
Poisoning/ Disease Disease (Refer Disease submission Occurrence incident not Submission
No. Disease cases with number of (death) incident incident
Disease (Refer (Refer Table without lost JKKP 7 (Refer (Refer operating JKKP 6
(Refer days away days away (20) (23) (24)
detected Table 12 ) Table 16 ) 17 ) workdays (21) Table 6 ) Table 4 ) (26) (27)
Table 18 ) from work from work
(12) (13) (14) (15) (19) (22) (25)
(16) (17) (18)
( Yes / No ) ( Yes / No )

Total:
_____Yes ____days _____Yes

Certification of Annual register totals by:

Title:

Date:
 JKKP 8( IV / IV )

1. Occupational Accident and Occupational Poisoning / Disease Register (Covering Calenda Year 20…………)
● Complete this section by copying totals from the annual register.
● If there were no Occupational accident, Occupational Poisoning or disease, please fill section Y & Z only.
OCCUPATIONAL ACCIDENT CASES OCCUPATIONAL POISONING AND DISEASE CASES
Total man-hours
Total Poisoning or
worked in Year 20………
Accident disease without lost
Total of Poisoning or
related Accident with lost Accident without Poisoning or disease with workdays
number of disease related
fatalities workdays lost workdays lost workdays
accidents fatalities
(death)
(Round up to the
nearest whole number)
Total Total average
Total Enter the Total number of
accident Total accident Poisoning or employment in
Number of number of Number of no. of days Poisoning/ disease
cases with cases without disease with Year 20………
daeths days away death away from cases
days away lost workdays lost workdays
from work work
from work
(Round up to the
nearest whole number)

** Note: 1 Day = 8 hours 1 death = 6000 day (lost days)

OCCUPATIONAL ACCIDENT CASES OCCUPATIONAL POISONING AND DISEASE CASES

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. of 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)

# Size of industry NAME:

B : Annual sales turnover > RM 25 mil. (Workers > 151 orang) TITLE:
M : Annual sales turnover = RM 10 - RM 25 mil. (Workes 51 - 150 orang)
S : Annual sales turnover < RM 10 mil. (Workers< 50 orang) SIGNATURE:

DATE: