ACCIDENT/INCIDENT REPORT FORM

Date of incident : 1 September 2014 Time : 12.40AM

Name of injured person: Mohamad Amirul Hakim Shamsudin , Mohd Rafi Abu
Address : 13 , Jalan Simpang 4 , Danga Bay , 81750 Johor Bahru

Phone Number(s) : 016-8884134

Date of birth : 16 September 1996 Gender: MALE__

Who was injured person : Passenger
Type of injury : The victim sustained severe head injuries and died on
the way to Hospital Sultan Ismail. However, the pillion rider escaped with minor
injuries.
Details of incident : The incident is believed to have occurred as a result of
'speeding' competition between two Mutsibishi Evo cars - one blue and the other
yellow. The driver of the blue Evo lost control and hit the motorcycle which was on
the left lane. The motorcyclist (Mohamad Amirul Hakim Shamsudin) was sustained
severe head injuries and died on the way to Sultanah Aminah Hospital .Yet, the
pillion rider ( Mohd Rafi Abu) was sustained minor injuries . _________
Injury requires physician/hospital visit? Yes

Name of physician/hospital : Sultanah Aminah Hospital __

Address : Jalan Abu Bakar, 80100 Johor Bahru, Johor __

Physician/hospital phone number: 07-223 3619 ____

Signature of injured party ______________________________________________
Date
*No medical attention was desired and/or required.
____________________________________________________________________
Signature of injured party Date
Return this form to Safety Coordinator within 24 hours of incident.