SHENA - Incident Reporting Form

Initial Incident Notification (IIN)

PART A: INFORMATION ABOUT THE INCIDENT/OCCUPATIONAL DISEASE/DANGEROUS OCCURENCE

Type of accident*

Location of Incident (as applicable for Occupational Disease)*

Company Business Activity*

Date of Incident / Diagnosis (for Occupational Disease)*

Time of Incident / Diagnosis (for Occupational Disease)*

Date of Incident first Notified to SHENA / Date of Diagnosis Report submitted to SHENA (for Occupational Disease)*

PART B: INFORMATION ABOUT REPORTER (EMPLOYER, DUTY HOLDER, OCCUPIER OR MEDICAL PRACTIONER)

Name*

Organisation*

Organisation's Address*

IC/Passport No.*

Current Designation*

Contact No. (Mobile Number)*

Contact No. (Office Number)*

Gender*

Female* Male*

Email Address*

PART C: INFORMATION ABOUT THE PERSON INVOLVED IN THE ACCIDENT/OCCUPATIONAL DISEASE/DANGEROUS OCCURENCE

Name*

Organisation*

IC/Passport Number*

BRUHIMS no.

Date of Birth*

Nationality*

Contact No. (Mobile Number)*

Contact No. (Office Number)*

Gender*

Female* Male*

Current Designation*

PART D: DESCRIPTION OF ACCIDENT/OCCUPATIONAL DISEASE/DANGEROUS OCCURENCE

Please describe the details of accident/ incident/ diagnosis of occupational disease*

Upload a document/picture/medical documents (for occupational disease)

REPORTING FORM FOR WORKPLACE ACCIDENT / OCCUPATIONAL DISEASE / DANGEROUS OCCURRENCE for the purpose of Workplace Safety and Health (Incident Reporting) Regulations, 2014

I hereby declare that the above information is accurate and true to the best of my knowledge. I understand that incomplete information will not be entertained and falsified reports with malicious intent may be subject to legal actions as relevant under the Workplace Safety and Health Order, 2009 and its regulations thereunder.

Please be informed that once a complaint is received, SHENA will respond to the Complainant within 3 working days of receipt including verification of Complainant’s details via the mobile number and email address provided with a request for further information or clarification if necessary. If no response from the Complainant of the request, then the complaint/report will be closed. Details of intervention carried out and its outcome will not be informed to the Complainant due to confidentiality issues.

Your identity will be kept confidential at all stages of the process and will not be disclosed to third parties or individuals who are the subject of your report.

Declaration of Complainant

I agree

Please check the box below to proceed

Initial Incident Notification (IIN)

Types of Reportable Incidents at a Workplace

Dangerous Occurrences

Second Schedule of Workplace Safety and Health Order, 2009

Occupational Diseases

Third Schedule of Workplace Safety and Health Order, 2009