BORANG LAPORAN KEMALANGAN PEKERJAAN, KEJADIAN BERBAHAYA DAN PENYAKIT PEKERJAAN / OCCUPATIONAL ACCIDENT,DANGEROUS OCCURRENCE & OCCUPATIONAL DISEASE REPORT FORM Nama/Name * No. Kad Pengenalan/Identification Card No. * Status Pelajar/Student Staf Pelawat/Visitor Kontraktor/Contractor Bahagian/Position & Kursus/Course Alamat Fakulti/Bahagian/Unit/Pejabat/Kolej (Faculty / Section / Unit / Office / College Address) No. Telefon (Pejabat)/Telephone No (Office) No.Telefon(Bimbit)/Telephone No. (HP No) Email * Salinan laporan akan dihantar melalui emel ini untuk tujuan rekod /A copy of the report will be sent through this email for record purposes Lokasi UTM * UTM KLUTM JBUTM Pagoh Nama/Name (mangsa/victim) * No. Kad Pengenalan(Mangsa)/Identification Card No. (victim) No.Telefon(bimbit)(mangsa)/Telephone No. (HP No.) (Victim) No. Telefon(Pejabat)(Mangsa)/Telephone No. (Office) (victim) Status (Mangsa/Victim) Pelajar/Student Staf Pelawat/Visitor Kontraktor/Contractor (Mangsa/Victim): Bahagian(Department) / Kursus(Course) Lokasi Kemalangan/Accident Location * Tarikh Kejadian/Date Of Occurence Masa/Time 121234567891011 : 0030 AMPM Butiran kejadian dan kejadian berbahaya (sebelum, semasa dan selepas (Details of incident and dangerous occurrence (before, during and after) * Restate the problem title and/or include more descriptive summary information. Muat Turun Lampiran(jika ada)/Upload Attachement (if) Drop a file here or click to upload Choose File Maximum file size: 33.55MB *untuk keselamatan/pengesahan, sila taip semula perkataan yang anda lihat ke dalam kotak disediakan Email Email If you are human, leave this field blank.