UNISEL-PT12-OS-PK01-BO01

Tarikh Efektif: 19 Julai 2022

No. Isu: 03

PUSAT PENGURUSAN RISIKO KESELAMATAN DAN KESIHATAN PEKERJAAN

(BORANG ADUAN / KEMALANGAN / KEJADIAN BERBAHAYA)

Maklumat Pengadu / Custom er’s I nformation

Nama / Name : Sharul No Telefon Bimbit /HP Number :

Emel / Email : Nombor Staf / Staff ID :

No Pelajar / Matric ID :

Maklumat Aduan / Complaint I nform ation

Cawangan /Branch : Kampus Bestari Jaya / Bestari Jaya Campus Perincian Lokasi / Location :
Kampus Shah Alam / Shah Alam Campus
Tajuk /Title : No Rujukan (jika berkenaan) /
Referrence Number (if applicable) : ___ /____
Perincian Aduan / Complaint Detail :
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Tandatangan / Sign : Tarikh / Date :

Maklumat Kemalangan/Kejadian Berbahaya /Accident/ Dangerous Occurrence I nform ation

Nama / Name : Mohd Shahrul Rizal bin Abdul Manap Jantina / Gender : Umur /
Lelaki / Male / Age : 39
Perempuan / Female
Fakulti/Jabatan / Faculty / Department : JPP Nombor Staf / Staf ID : No Telefon Bimbit /
121317 HP Number :

Mangsa dihantar ke / Victim was sent to :

Hospital (hospital)/ Klinik (Clinic) / Rumah (Home) / Kembali Bekerja (Back to office) /
Lain-lain (Others) :

Cuti sakit (Medical leave) : __ /__ /____ hingga (to) __ /__ /____ ( ______ Hari / Day )

Perincian Kemalangan/Kejadian Berbahaya / Accident/Dangerous Occurence Detail :

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

PENGESAHAN PPRKKP

_____________________________________________________________________________________ Aduan Selesai

_____________________________________________________________________________________ Tidak Selesai
__________________________________________________________________________________________________________
Tandatangan / Sign : Tarikh / Date :

Perakuan Siap Kerja

Penilaian Pengadu
Aduan/ Kemalangan/ Kejadian Berbahaya diambil tindakan pada : __ /__ /____ . Tahap Perkhidmatan PPRKKP :
Sangat Memuaskan
Memuaskan
__________________________
Tidak Memuaskan
Tandatangan & Cop Pengesahan