. WEHU Al (JKKP 6) NOTIFICATION OF OCCUPATIONAL ACCIDENT AND DANGEROUS OCCURRENCE Location of accident/incident Send to: Part B - Affected person (If more than one Pengarah Kesihatan Negeri person please list the name in Part C) Jabatan Kesihatan Negeri aes es Name Date of birth ee ms] 5 DD MM YY Part A - Detail of Notifier New IC/ Passport no. Nationality Te The ee Name, — Gender [| male [-] Female Occupation aa Designation aaa Ethnic group Name and address of organization Name and address of organization District, State Contact no. Duration of current job SSIES TRIES ESSA SE SaE EP TEER] Date of first informing DOSH Ee c) Why did Signature of a) What were the activities involved prior to the accident 7 b) What actually happened during the accident (agent involved and effect to the person involved) ? Part C - Description of accident or dangerous occurrence the accident happen? d) What were the actions taken following the accident ? Notifier Date aeDate of notification Name of facility Unit / Department / Ward ‘WEHU A2 Date seen/treated/admitted Medical certificate (MC) given |_| No Yes Duration of MC days 1 Nature of injury (1 Abrasions © Amputation © Asphyxia © Burns (heat) 2 Bums (chemical) (2 Bruises and contusions C Coneussions @ cuts LD Dislocation (Effect of radiation O Fracture @ Drown | Laceration (© Sharp injuries TD Sprain & strain [Gi intemal injuries © splash of blood/body fluid (2 Splash of chemicals © Effect of electric currents Others (please specify) 2. Part of Body Injured Head and Neck Upper Limbs Torso Lower Limbs O scalp 1 Upper arms R/L Back hip RL skull OD Elbow RIL, (i Chest (Thigh RIL eyes RA (Forearm = RIL (1 Abdomen (leg RL leas RL OD wrist RIL 1 Pelvis [knee RIL CO Nose G Hand RIL © Groin Gi ankle RL D2 mouth Opam RIL GiFeet RIL CO Teeth Fingers RIL TiToes RIL CO Face (5 other specity: (Neck 3. Mechanism of accident [GB Exposure to / or contact with harmful substances / radiation [& Exposure to / or contact with electric currents {@ Exposure to explosion @ Drowning © Crush by moving / sliding object © Needle stick / Needle prick © Physical assault (2 Struck against object [1 Struck by sliding falling, flying or other moving object {Motor vehicle accident ( Caught in / or between object Co Fall or slip on same level (| Fall from height {1 Injured while handiing, lifting or carrying (© Contact with extreme temperature