PERSONAL ACCIDENT & HEALTH

• Document No.

• Conducted on

  Date

• Prepared by

DETAIL

• NAME :

• STAFF ID :

• NRIC :

• ADDRESS

• TEL. NO :

• DEPARTMENT :

• SECTION :

• DESIGNATION :

• DATE OF EMPLOYMENT :

• DISEASES / INJURY :

• FIST TREATMENT :

• SECOND TREATMENT :

• ADMITTED DATE :

• DISCHARGE DATE :

• MC FORM :

• MC UNTIL :

ACCIDENT DETAIL

• DATE OF ACCIDENT :

• TIME OF ACCIDENT :

• PLACE OF ACCIDENT :

• DESCRIBE BRIEFLY HOW IT HAPPENED :

• DESCRIBE BRIEFLY THE INJURIES SUSTAINED :

• NAME OF PERSON WHO WITHNESSED THE ACCIDENT

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• NAME OF CLAIMANTS

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