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JKKP 8 ( I ) /( IV )

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

Body Type of Outcome accident * Accident with lost workdays


Type of injury Agent causing Date of
Location of Accident
Enter number of (Refer to injury submission
Bil: injury (Refer (Refer Accident cases with Accident without
PD NPD D days away from Table 10) (Refer to JKKP 6
Table 12) Table 9) days away from work lost workdays (9) Table 11) (10)
(2) (3) (4) (5) work (11)
(1) (6) (8)
(7)
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
Yes / No Yes / No
Yes / No Yes / No
Total ________Yes _________days _______Yes

* 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

Certification of Annual Register Totals by: ……………………………………….


Title: ……….……………………………………… Date:…………………………….
JKKP 8( IV / IV )
1. Occupational Accident and Occupational Poisoning / Disease Register (Covering Calendar Year 20…….)
● Complete this section by copying totals from the annual register.
● Leave this section blank if there were no Occupational Accident, Occupational Poisoning or Disease, please fill Y and Z only
OCCUPATIONAL ACCIDENT CASES OCCUPATIONAL POISONING AND DISEASE Total man-hours
worked in Year 20…..
Total Poisoning / Y
Total of Poisoning / Disease without lost
Accident related Accident with lost Accident without Poisoning / Disease with
number of Disease related workdays
fatalities (death) workdays lost workdays lost workdays (Round up to the
accidents fatalities
W nearest whole number)
Total average
Total Total number of employment in Year
Total Enter the Poisoning / Disease 20……
accident Total accident Poisoning /
Number of number of Number of no. of days cases
cases with cases without Disease with
Deaths days away Death away from Z
days away lost workdays lost workdays
from work work
from work
X
(Round up to the
nearest whole number)
0 1 6 0 0 0 0 V

** Note: 1 day = 8 hours 1 death = 6000 days (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. 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 Industry: NAME : ……………………………………………………………………..

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 : ………………………………………………………………………