JKKP 7

REPORT FOR OCCUPATIONAL POISONING / OCCUPATIONAL DISEASE OCCUPATIONAL SAFETY AND HEALTH
(NOTIFICATION OF ACCIDENT, DANGEROUS OCCURANCE, OCCUPATIONAL POISONING AND OCCUPATIONAL DISEASE) REGULATION 2004

Part A1 Part A2
Notifier - Regulation 7(1) Employer Notifier - Regulation 7(2) Registered Medical Practitioner
(If more than one person please use separate form)
Name Name

Designation Designation

Name & Address of Organisation Address of Clinic / Hospital

Chin Enterprise
Jalan Rembia Dalam, Rembia,
78000, Alor Gajah, Melaka.
Contact Number Contact Number

R.O.C. No 009554776 JKKP Reg. No

Industrial Classification Code (Table 3)

Contact person (if different from above)

Part B - Affected Person Part C - Occupational Poisoning / Disease

Name Diagnosis / Provisional Diagnosis

Chin Yok Peng High fever and later was diagnosed with Leptospirosis
Date of Birth 16/09/1996 Date of Diagnosis

NIRC/Passport No 960916-04-3151
21st March
L/P
Nationality malaysian Gender Name and Address of Attending Doctor

Occupation Administrator DR. Syamim Sins

Name & Addrress of Organisation Montreal, Quebec, Canada
Chin Enterprise
Jalan Rembia Dalam, Rembia,
78000, Alor Gajah, Melaka.

Location of incident

Jalan Rembia Dalam, Rembia,

78000, Alor Gajah, Melaka.

Part D
Description of work that led to occupational poisoning/disease (Please describe any work done by the affected person which might have led to them getting
the disease is thought to have been caused by exposure to an agent at work, e.g.a specific chemical - please state what that agent is)
Before been moved to administration office because of his good performance, Chin Yok Peng worked at the
Farm that handled the bird. Maybe he was infected during that work because of the exposure with the bird

Rahmat
Signature of Notifier

Date

Disclaimer
Completing this form does not constitute to an admission of liability of any kind by the person making the report or by any other person(s)
Department of Occupational Safety and Health Ministry of Human Resources Malaysia 2005