UNIVERSITI MALAYA
LAPORAN KEMALANGAN/INSIDEN
SEKSYEN I - BUTIR-BUTIR PELAPOR
Nama : ___________________________________________________________________________
Jawatan (sekiranya berkerja di UM): ____________________________________________________
Tempat Kerja : _____________________________________________________________________
No. K.P. : _______________________
(Baru)
______________________(Lama)
No. Tel. : ________________________
(Pejabat)
______________________ (Rumah)
Alamat Dihubungi: __________________________________________________________________
__________________________________________________________________________________
SEKSYEN II - BUTIR-BUTIR KEMALANGAN/INSIDEN
Tempat Kemalangan/Insiden: _________________________________________________________
Tarikh Kemalangan/Insiden : _________________________________________________________
Masa Kemalangan/Insiden : _________________________________________________________
Keterangan Lanjut Tentang Kemalangan/Insiden: (Gunakan kertas tambahan jika perlu) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
__________________________ Tandatangan
Tarikh Laporan: ________________
UNIVERSITI MALAYA
LAPORAN PENYIASATAN KEMALANGAN
Arahan : Diisi Oleh Ahli Jawatankuasa Keselamatan dan Kesihatan dan Ketua Pusat Tanggungjawab Tandakan Yang Berkenaan
SEKSYEN I - BUTIR-BUTIR PUSAT TANGGUNGJAWAB
Nama & Alamat: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
No. Tel : ____________________________
No. Fax : ____________________________
SEKSYEN II - BUTIR-BUTIR MANGSA
Nama Penuh: ______________________________________________________________________
No. K.P.:___________________________(Lama) ___________________________________( Baru)
Umur: ______________ Tahun
Jantina:
L
P
Jawatan: _________________________
Tugas Biasa Mangsa: __________________________________________________________________________________ __________________________________________________________________________________
Tempoh Berkhidmat: _____________ Tahun ____________ Bulan Status Perkhidmatan: Tetap
Sementara
Kontrak
___________ (Lain-lain)
Alamat Tempat Tinggal: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
SEKSYEN III - MAKLUMAT KEMALANGAN
Tarikh Kejadian: ______________________
Pada Masa Kerja:
Biasa
Syif
Masa: ___________________ Pg/Ptg/Mlm
Lebih Masa
___________ (Lain-lain)
Tempat Kejadian: __________________________________________________________________________________ __________________________________________________________________________________
Tugas Yang Dilakukan Ketika Kemalangan/Insiden: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
Bil. Hari Cuti Sakit: _______________ Tarikh Mula: ________________ Hingga: ______________
Jenis Kecederaan/Penyakit :
Kekal
Tidak Kekal
Maut
(Sila lampirkan Laporan Perubatan, Sijil Kematian dan Laporan Autopsi)
Sila Nyatakan Anggota Badan Yang Cedera/Cacat/Sakit: __________________________________________________________________________________
Rawatan Diberi: __________________________________________________________________________________ __________________________________________________________________________________
Hospital/Klinik : __________________________________________________________________________________
Perbelanjaan Kos Yang Berbangkit: __________________________________________________________________________________
Perihalkan Kerosakan Harta Benda (Jika Ada): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
SEKSYEN IV - LANGKAH PENGAWALAN KEMALANGAN SEBELUM KEJADIAN
Alat Perlindungan Diri (PPE) Yang Dibekalkan Kepada Mangsa :
Kasut Keselamatan
Topi Keselamatan
Perlindungan Pendengaran
Perlindungan Pernafasan
Perlindungan Mata
_____________________
Penyeliaan: Secara Langsung
Tidak Langsung
Tiada
Tidak Diperlukan
Bil. Staf Di bawah Pengawasan Penyelia: ___________________ Orang
Prosedur Kerja Selamat Untuk Kerja Terbabit :
Ada
Tiada
Nama Penyelia: ____________________________________________________________________
Ciri-ciri Keselamatan Yang Ada Pada Jentera Terbabit (Jika Berkaitan): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
Senaraikan Latihan/Kursus Yang Telah Diberikan Kepada Mangsa (Jika berkaitan): Tarikh
Modul Latihan/Kursus
Tempat
SEKSYEN V - PERIHAL KEMALANGAN
Catitkan mengikut turutan, kejadian yang membawa kepada kemalangan tersebut. Gunakan kertas tambahan jika perlu. Masa
Keterangan Aktiviti
SEKSYEN V - PERIHAL KEMALANGAN (Sambungan)
Sila lakar/lukis (sketch/draw) bagaimana kejadian ini berlaku. Gunakan kertas tambahan jika perlu.
Sertakan foto yang menunjukkan bahan/loji/tempat kejadian.
SEKSYEN VI - FAKTOR-FAKTOR PENYEBAB KEMALANGAN
Huraikan keadaan tidak selamat: __________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
Huraikan tingkahlaku tidak selamat: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Huraikan faktor lain: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ SEKSYEN VII - LANGKAH-LANGKAH PEMBETULAN DAN PENCEGAHAN KEMALANGAN DARIPADA BERULANG
Langkah Segera: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
Nama Pegawai Bertanggungjawab: _____________________________________________________
Tarikh Sasaran: ___________________________________
Langkah Jangka Pendek: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
Nama Pegawai Bertanggungjawab: _____________________________________________________
Tarikh Sasaran: ___________________________________
Langkah Jangka Panjang: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
Nama Pegawai Bertanggungjawab: _____________________________________________________
Tarikh Sasaran: ___________________________________
SEKSYEN VIII - BUTIR SAKSI (Sila lampirkan Laporan Saksi jika ada)
Nama
Jawatan
No. K.P
SEKSYEN IX - HAL-HAL LAIN (Jika Ada) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
SEKSYEN XI
-
NAMA
SEKSYEN XII
-
BUTIR-BUTIR AHLI JAWATANKUASA JKK YANG MEMBANTU DALAM MENYEDIAKAN LAPORAN
NO. KAD PENGENALAN
JAWATAN
TANDATANGAN
BUTIR-BUTIR KETUA PUSAT TANGGUNGJAWAB YANG MENYEMAK LAPORAN
Nama: ____________________________________________________________________________
No. K.P : ___________________________
Jawatan: __________________________
____________________________ Tandatangan
Tarikh: _____________________
Laporan Penyiasatan Kemalangan
UNIVERSITI MALAYA
LAPORAN MANGSA
SEKSYEN I - BUTIR-BUTIR MANGSA
Nama : __________________________________________________________________________
No. K.P : ___________________________
(Baru)
______________________ (Lama)
Tarikh Lahir : _____________________________
Jantina : _________________________________
Tempat Kerja : _____________________________________________________________________
Jawatan (sekiranya di Universiti Malaya): ________________________________________________
No. Tel. : ___________________________
(Pejabat)
______________________ (Rumah)
Alamat Untuk Dihubungi: _____________________________________________________________
SEKSYEN II - BUTIR-BUTIR KEMALANGAN
Jenis Penyakit/Kecederaan/Kerosakan(beri keterangan lanjut): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
Tempat Penyakit Dikesan/Kemalangan/Insiden/Kerosakan : _________________________________
Tarikh Penyakit Dikesan/Kecederaan/InsidenKerosakan: ____________________________________
Masa Penyakit Dikesan/Kemalangan/Insiden/Kerosakan : ___________________________________
Keterangan Lanjut Tentang Penyakit/Kemalangan/Insiden/Kerosakan : (Gunakan kertas tambahan jika perlu)
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ___________________________________________________________________ Ulasan lain ( jika ada) : __________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ (Sila lampirkan Laporan Pemeriksaan Kesihatan)
SEKSYEN III - BUTIR-BUTIR ORANG YANG MENGISI BORANG INI (sekiranya selain dari mangsa sendiri)
Nama: ___________________________________________________________________________
Jawatan (sekiranya di Universiti Malaya): ________________________________________________
Tempat Kerja: _____________________________________________________________________
Hubungan dengan Mangsa : ___________________________________________________________
No. Tel: _________________________ (Pejabat)
______________________ (Rumah)
Alamat UntukDihubungi: _____________________________________________________________
__________________________________________________________________________________
__________________________ Tandatangan
Tarikh Laporan: ________________
*Borang
yang
lengkap
diisi
hendaklah
dikemukakan
Penyakit/Kemalangan/Insiden/Kerosakan tersebut berlaku.
Laporan Mangsa
kepada
Ketua
PTj
di
mana
UNIVERSITI MALAYA
LAPORAN SAKSI
SEKSYEN I - BUTIR-BUTIR SAKSI
Nama : ___________________________________________________________________________
Jawatan (sekiranya berkerja di UM): ____________________________________________________
Tempat Kerja : _____________________________________________________________________
No. K.P. : _________________________
(Baru)
______________________ (Lama)
No. Tel. : _________________________
(Pejabat)
______________________ (Rumah)
Alamat Untuk Dihubungi: _____________________________________________________________
__________________________________________________________________________________
SEKSYEN II - BUTIR-BUTIR KEMALANGAN/INSIDEN
Tempat Kemalangan/Insiden: _________________________________________________________
Tarikh Kemalangan/Insiden : _________________________________________________________
Masa Kemalangan/Insiden : _________________________________________________________
Keterangan Lanjut Tentang Kemalangan/Insiden: (Gunakan kertas tambahan jika perlu) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
Saya telah membaca yang tersebut di atas/memahami apa yang dibaca kepada saya dan mengakui bahawa semuanya betul dan benar sepanjang pengetahuan saya.
__________________________ Tandatangan
Tarikh Laporan: ____________________
