Workplace Accident Report Form (Malaysia)
WORKPLACE ACCIDENT / INCIDENT REPORT FORM
Occupational Safety and Health Act 1994 (OSHA 1994, Act 514) | NADOPOD Regulations 2004 | Employees' Social Security Act 1969 (Act 4)
Date of Report: [Report Date]
CONFIDENTIAL — FOR SAFETY AND HEALTH OFFICER USE
SECTION A: INCIDENT DETAILS
Date of Incident: [Incident Date]
Time of Incident: [Incident Time]
Exact Location: [Incident Location]
Type of Incident: [Incident Type]
SECTION B: INJURED / AFFECTED PERSON DETAILS
Full Name: [Injured Name]
NRIC / Passport / Work Permit No.: [Injured NRIC]
Designation: [Injured Designation]
Department: [Injured Department]
SOCSO Member No.: [SOCSO Member No]
Employment Status: [Employment Status]
SECTION C: NATURE OF INJURY AND ACCIDENT DESCRIPTION
Nature of Injury: [Nature of Injury]
Body Part Affected: [Body Part Affected]
Agent / Cause: [Injury Agent]
Description of Accident:
[Accident Description]
Witnesses: [Witnesses]
SECTION D: IMMEDIATE ACTIONS AND NOTIFICATIONS
First Aid / Treatment Provided: [First Aid Provided]
DOSH Notification Status: [DOSH Notified]
DOSH Reference No.: [DOSH Ref No]
Note: SOCSO Form 34 (Borang 34) must be submitted to SOCSO within 48 hours of this accident for insured employees under the Employees' Social Security Act 1969 (Act 4).
SECTION E: DECLARATION AND SIGNATURES
Report Prepared By: [Reported By]
Safety and Health Officer Signature: ____________________________
Date: [Report Date]
Immediate Supervisor Signature: ____________________________
Date: ____________________________
Management Representative Signature: ____________________________
Date: ____________________________
CORRECTIVE ACTIONS (to be completed within 7 days)
Root Cause: ____________________________
Corrective Action: ____________________________
Responsible Person: ____________________________
Target Completion Date: ____________________________
Safety and Health Officer
________________
Signature
Injured Person / Representative
________________
Signature
What Is a Workplace Accident Report Form (Malaysia)?
A Workplace Accident Report Form in Malaysia sets out the information or analysis it captures for compliance or operational use.
Under Regulation 7 of the NADOPOD Regulations 2004, the occupier of the workplace must notify DOSH of: (a) any accident causing death — immediately by the fastest available means and by JKKP 6 within 7 days; (b) any accident causing an employee to be incapacitated for more than 4 consecutive days — by JKKP 6 within 7 days; (c) any dangerous occurrence as listed in the First Schedule to the NADOPOD Regulations (e.g. scaffold collapse, explosion, fire, collapse of a lifting appliance) — immediately and by JKKP 6 within 7 days; and (d) any occupational poisoning or occupational disease listed in the Third Schedule — by JKKP 6 within 7 days. Notifications are submitted through the DOSH Online System at oshims.dosh.gov.my.
An internal Workplace Accident Report Form also supports the employer's legal obligations under the Employees' Social Security Act 1969 (Act 4) administered by SOCSO (PERKESO) — the Social Security Organisation of Malaysia. Where the injured employee is insured under SOCSO's Employment Injury Insurance (Scheme A), the employer must submit SOCSO Form 34 (Borang 34) within 48 hours of the accident to SOCSO to initiate the employee's Employment Injury benefits claim under Section 14 of the SOCSO Act 1969. SOCSO benefits include medical benefits, temporary disability benefits (80% of the insured daily wage), permanent disablement benefits, and dependants' benefit in the event of a fatal accident.
The Accident Report Form also serves as a foundational document for the employer's internal accident investigation, which is required under the OSH Management System Guidelines (MS 1722:2011) and is a prerequisite for CIDB-registered construction companies maintaining their CIDB Green Card contractor safety accreditation.
The legal framework governing the Workplace Accident Report Form (Malaysia) in Malaysia draws on several key statutes and regulatory bodies. Under Malaysian law, the Contracts Act 1950 (Act 136) governs contractual obligations. The Companies Act 2016 (Act 777) regulates corporate entities through the Companies Commission of Malaysia (SSM). The Employment Act 1955 (Act 265) and the Department of Labour govern employment matters. The Personal Data Protection Act 2010 (Act 709) and the Personal Data Protection Department protect personal data. The Inland Revenue Board of Malaysia (LHDN) administers tax obligations. The Industrial Court adjudicates employment disputes under the Industrial Relations Act 1967 (Act 177). Parties executing a Workplace Accident Report Form (Malaysia) in Malaysia should confirm the document reflects current law, including any amendments enacted since the original drafting date. The Employment Act 1955 (Act 265) sets the foundational requirements.
When Do You Need a Workplace Accident Report Form (Malaysia)?
A Workplace Accident Report Form is required in Malaysia whenever a work-related accident, injury, near-miss, dangerous occurrence, occupational poisoning, or occupational disease occurs at the employer's workplace.
An Accident Report Form is needed when any employee sustains an injury at work — from a minor cut or sprain to a serious fracture or amputation — to create a contemporaneous record of the circumstances, causes, and immediate actions taken, which is essential for DOSH NADOPOD reporting and SOCSO Employment Injury claims.
An Accident Report Form is required when a dangerous occurrence listed in the First Schedule to the NADOPOD Regulations 2004 takes place at the workplace — such as the collapse of a scaffold, the explosion of a pressure vessel, an electrical flashover, or the uncontrolled release of a hazardous substance — regardless of whether any person was injured.
An Accident Report Form is needed when an employee is diagnosed with an occupational disease or occupational poisoning listed in the Third Schedule to the NADOPOD Regulations 2004 — such as noise-induced hearing loss, occupational asthma, or chemical poisoning — to initiate notification to DOSH and SOCSO.
An Accident Report Form is required when a contractor or visitor is injured at the employer's workplace, as the occupier of the workplace bears reporting obligations under Section 32 of the OSHA 1994 regardless of whether the injured person is a direct employee.
An Accident Report Form is needed following any near-miss incident — an event that did not result in injury but had the potential to do so — as part of the employer's hazard prevention programme and OSH Management System under MS 1722:2011 and ISO 45001.
Parties in Malaysia should prepare a Workplace Accident Report Form (Malaysia) proactively rather than waiting for a dispute to arise. Courts interpret agreements based on the written terms rather than oral representations. Under Malaysian law, the Contracts Act 1950 (Act 136) governs contractual obligations. The Companies Act 2016 (Act 777) regulates corporate entities through the Companies Commission of Malaysia (SSM). The Employment Act 1955 (Act 265) and the Department of Labour govern employment matters. The Personal Data Protection Act 2010 (Act 709) and the Personal Data Protection Department protect personal data. The Inland Revenue Board of Malaysia (LHDN) administers tax obligations. The Industrial Court adjudicates employment disputes under the Industrial Relations Act 1967 (Act 177). Where the transaction involves regulated activities, prior approval from the relevant authority may be required before execution.
What to Include in Your Workplace Accident Report Form (Malaysia)
A valid Malaysia Workplace Accident Report Form must contain the following essential elements to support DOSH NADOPOD reporting, SOCSO claims, and internal accident investigation.
Accident Location and Date: The exact location within the workplace (e.g. Machine Shop Floor, Level 3 Staircase), the date in DD/MM/YYYY format, and the time of the accident. For dangerous occurrences, the exact time is required for the DOSH JKKP 6 Form.
Injured Person Details: Full name, NRIC or passport number, designation, department, employment status (permanent, contract, or outsourced), and SOCSO member number. The SOCSO number is required for the SOCSO Form 34 (Borang 34) submission under the Employees' Social Security Act 1969 (Act 4).
Nature and Cause of Injury: A description of the type of injury (e.g. laceration, fracture, burn, chemical exposure), the body part affected, and the agent or mechanism of injury (e.g. machinery, fall from height, chemical splash). The DOSH JKKP 6 Form uses standardised injury codes for NADOPOD reporting.
Description of Accident: A factual, chronological account of how the accident occurred — what the injured person was doing, what went wrong, and the immediate sequence of events. Eyewitness accounts should be recorded separately.
Immediate Actions Taken: First aid treatment provided, name of first aider, whether the injured person was taken to a clinic or hospital (and which hospital), and whether emergency services were called.
Witness Details: Names and designations of all persons who witnessed the accident or were in the vicinity.
DOSH Notification Status: Whether and when DOSH was notified (immediate telephone notification for fatal/dangerous occurrences; JKKP 6 within 7 days), and the DOSH reference number once assigned.
Supervisor and Management Acknowledgement: Signatures of the injured person's immediate supervisor and the Safety and Health Officer (SHO) confirming the report has been reviewed, with corrective actions identified.
Additional compliance elements for a Workplace Accident Report Form (Malaysia) used in Malaysia include: Under Malaysian law, the Contracts Act 1950 (Act 136) governs contractual obligations. The Companies Act 2016 (Act 777) regulates corporate entities through the Companies Commission of Malaysia (SSM). The Employment Act 1955 (Act 265) and the Department of Labour govern employment matters. The Personal Data Protection Act 2010 (Act 709) and the Personal Data Protection Department protect personal data. The Inland Revenue Board of Malaysia (LHDN) administers tax obligations. The Industrial Court adjudicates employment disputes under the Industrial Relations Act 1967 (Act 177). Forms-legal.com provides this template as a starting point for Malaysia-compliant documentation.
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Reference this free template in an article, syllabus, or research note:
Forms Legal. (2026). Workplace Accident Report Form (Malaysia) (Malaysia) [Legal document template]. Forms Legal. https://forms-legal.com/malaysia/employment/forms/accident-report-form-malaysia
"Workplace Accident Report Form (Malaysia) (Malaysia)." Forms Legal, 2026, https://forms-legal.com/malaysia/employment/forms/accident-report-form-malaysia.
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author = {{Forms Legal}},
title = {Workplace Accident Report Form (Malaysia) (Malaysia)},
year = {2026},
howpublished = {\url{https://forms-legal.com/malaysia/employment/forms/accident-report-form-malaysia}},
note = {Free legal document template. Based on Employment Act 1955 (Act 265)}
}
Frequently Asked Questions
Under the Occupational Safety and Health (Notification of Accident, Dangerous Occurrence, Occupational Poisoning and Occupational Disease) Regulations 2004 (NADOPOD), the occupier of the workplace must notify the Department of Occupational Safety and Health Malaysia (DOSH) as follows: fatal accident — notify DOSH immediately by telephone to the nearest DOSH office and submit DOSH Form JKKP 6 within 7 days; non-fatal accident causing incapacity exceeding 4 consecutive days — submit JKKP 6 within 7 days; dangerous occurrence (scaffold collapse, explosion, etc.) — notify immediately and submit JKKP 6 within 7 days; occupational poisoning or disease — submit JKKP 6 within 7 days of diagnosis. JKKP 6 forms are submitted through the DOSH Online Reporting System at oshims.dosh.gov.my. Failure to notify DOSH within the required timeframe is an offence under Section 53 of the OSHA 1994 (Act 514), punishable by a fine not exceeding RM50,000 or imprisonment not exceeding 2 years.
Yes. Under the Employees' Social Security Act 1969 (Act 4), where an employee insured under SOCSO's Employment Injury Insurance (Scheme A) sustains a work-related injury or contracts an occupational disease, the employer must submit SOCSO Form 34 (Borang 34 — Accident Report) to the nearest SOCSO office within 48 hours of the accident. SOCSO Form 34 initiates the employee's Employment Injury claim, which may cover medical benefits (full medical expenses), temporary disability benefits (80% of insured daily wage for the duration of incapacity), and permanent disablement benefits. For fatal accidents, the employer must also submit SOCSO Form 34 to initiate the Dependants' Benefit claim for the employee's dependants. Failure to report to SOCSO within 48 hours is an offence under the Employees' Social Security Act 1969.
A dangerous occurrence under the NADOPOD Regulations 2004 is an unplanned event specified in the First Schedule to the Regulations that must be reported to DOSH regardless of whether any person was injured. Dangerous occurrences listed in the First Schedule include: collapse or failure of a scaffold 5 metres or more in height; uncontrolled explosion; accidental ignition or explosion of explosives; electrical short circuit or failure causing fire or explosion; bursting of a closed vessel or pressurised pipeline; collapse of a building or structure; collapse or failure of a crane or other lifting appliance; contact with overhead electric lines; and uncontrolled release, spillage, or leakage of a flammable, explosive, or toxic substance. Any of these events must be notified to DOSH immediately by telephone and followed up with DOSH Form JKKP 6 within 7 days, whether or not injuries were sustained.
An employee insured under SOCSO's Employment Injury Insurance (Scheme A) under the Employees' Social Security Act 1969 (Act 4) is entitled to the following benefits for work-related injuries: Medical Benefit — all reasonable medical, surgical, and hospitalisation expenses covered at SOCSO panel clinics or hospitals; Temporary Disability Benefit — daily allowance equal to 80% of the insured daily wage (subject to a minimum and maximum) for the duration of temporary incapacity, payable from the first day; Permanent Disability Benefit — a lump sum or monthly pension calculated on the degree of permanent disablement, assessed by a Medical Board; Constant Attendance Allowance — additional benefit for severely disabled employees; Dependants' Benefit — monthly pension and a funeral grant for dependants in the event of a fatal accident; and Rehabilitation Benefit — physical and vocational rehabilitation services. All benefits are funded by SOCSO contributions — there is no out-of-pocket cost to the employee.
Under the Employees' Social Security Act 1969 (Act 4), SOCSO Employment Injury coverage follows the employment relationship — the insured person is an employee covered by SOCSO contributions made by their own employer. A contractor injured at a principal employer's workplace is covered under SOCSO through the contributions paid by the contractor's own employer (the contracting company), not by the principal employer. However, the principal employer (occupier of the workplace) remains liable under Section 32 of the OSHA 1994 (Act 514) for reporting the accident to DOSH, as the NADOPOD reporting obligation applies to the occupier regardless of whether the injured person is a direct employee or a contractor's worker. The principal employer may also face civil liability for the contractor's injuries if the accident was caused by the principal employer's failure to maintain a safe workplace under Section 15 of the OSHA 1994.
This template is provided for informational purposes only and does not constitute legal advice. Laws vary by jurisdiction and change over time. Consult a qualified attorney for advice specific to your situation.Full disclaimer
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