Information
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Document No.
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Conducted on
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Prepared by
DETAIL
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NAME :
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STAFF ID :
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NRIC :
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ADDRESS
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TEL. NO :
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DEPARTMENT :
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SECTION :
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DESIGNATION :
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DATE OF EMPLOYMENT :
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DISEASES / INJURY :
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FIST TREATMENT :
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SECOND TREATMENT :
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ADMITTED DATE :
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DISCHARGE DATE :
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MC FORM :
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MC UNTIL :
ACCIDENT DETAIL
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DATE OF ACCIDENT :
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TIME OF ACCIDENT :
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PLACE OF ACCIDENT :
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DESCRIBE BRIEFLY HOW IT HAPPENED :
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DESCRIBE BRIEFLY THE INJURIES SUSTAINED :
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NAME OF PERSON WHO WITHNESSED THE ACCIDENT
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NAME OF CLAIMANTS