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
Muhamad and Nur Lee Sze Hoy

Designation Designation
Mr Dr

Name & Address of Organisation Address of Clinic / Hospital

Muhamad and Nur Shipyard Melaka Klinik Putra One,
Persiaran Bukit Rahman Putra,
47000 Sungai Buloh,
Selangor.
Contact Number Contact Number
0112334456 0123456789

R.O.C. No 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
Tan Yi Shiu Asbestosis , Noise Induced Hearing Loss

Date of Birth 24-9-1955 Date of Diagnosis

NIRC/Passport No 550924-02-5547 25th July 2018

Malaysian Gender Male

Nationality Name and Address of Attending Doctor
Female Dr Lee Sze Hoy,
Klinik Putra One,
Occupation Retiree Persiaran Bukit Rahman Putra,
Name & Address of Organisation 47000 Sungai Buloh,
Selangor.
-

Location of incident
Muhamad and Nur Shipyard 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)
Sandblasting paint off the ships , Removed the insulation on the ships boiler pipes several times a year in the course of his work - exposure to Asbestos ,
Noise induced hearing loss

Signature of Notifier

Date 25th July 2018

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)