. 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