Outlet Incident Report Form / Borang Laporan Insiden Kedai
Outlet Code
*
Brand
*
Outlet Name
*
Own By
Ownership
*
HOD Email
*
Outlet OM
OM Email
Store Format
*
State
Address
Date & Time of Incident / Tarikh & Masa Insiden
*
-
Day / Hari
-
Month / Bulan
Year / Tahun
Date Picker Icon
Hour / Jam Minutes / Minit
AM
PM
AM/PM Option
Back
Next
Incident Involved / Insiden Melibatkan
*
Please Select
Staff / Pekerja
Customer / Pelanggan
Staff & Customer / Pekerja & Pelanggan
Vendor / Vendor
Place Of Incident / Tempat Insiden
*
Please Select
Workstation / Stesen Kerja
Storeroom or Cabin Storage / Bilik Stor atau Stor Kabin
Dining Area / Kawasan Makan
Toilet / Tandas
Common Walkway / Laluan Pelanggan
Main Entrance / Pintu Utama
Back Door / Pintu Belakang
Road Accident / Kemalangan Jalan Raya
-------- FOR HQ ONLY --------
Ground Floor (Block A)
First Floor (Block A)
Ground Floor (Block B)
First Floor (Block B)
Name Of Person Involved / Nama Orang Yang Terlibat
*
IC Number / Nombor Kad Pengenalan
*
Person involved IC number / Nombor kad pengenalan orang yang terlibat
Contact Number / Nombor Telefon
*
Person involved contact number / Nombor telefon orang yang terlibat
Nationality / Warganegara
*
Please Select
Malaysian / Malaysian
Non Malaysian / Bukan Malaysian
Employment Type / Jenis Pekerjaan
Please Select
Full Time Staff
Part Time Staff
Contract Worker
Non-Employed Staff (Visitor / Customer / Contractor)
Only for Tealive & Baskbear staff / Untuk pekerja Tealive & Baskbear
Gender / Jantina
*
Please Select
Male / Lelaki
Female / Perempuan
Enter Employee ID
*
LINxxxxx / EVGxxxxx / PRDxxxxx
First Working Date / Hari Pertama Bekerja
*
-
Day
-
Month
Year
Enter the staff first working date / Masukkan hari pertama staff tersebut bekerja
Length of Services
Details Of Incident / Butiran Kejadian
*
Please write as detail as possible / Sila tulis butiran teperinci
Action Taken During Incident Happen / Tindakan Diambil Semasa Insiden Berlaku
*
Offer Help First Aid Kit or Assistance / Tawarkan Bantuan Kit Pertolongan Kecemasan atau Bantuan
Contacted Nearest Clinic - Hospital - Police Station - Fire Department / Dihubungi Klinik - Hospital - Balai Polis Terdekat - Bomba
Send The Victim To Nearest Clinic - Hospital - Police Station / Hantar Mangsa Ke Klinik Terdekat - Hospital - Balai Polis
Informed Immediate Superior (AM / OM) / Maklumkan Insiden Kepada Pihak Atasan (AM / OM)
Upload Photo and Video Of Incident / Muat Naik Gambar dan Video Insiden
*
Browse Files
Drag and drop files here
Choose a file
Only for pictures or videos of injuries, CCTV footage during incident time & MC if available / Hanya untuk gambar atau video kecederaan, rakaman CCTV masa incident & MC jika ada
Cancel
of
Submitted By / Dihantar Oleh
*
Informer Name / Nama Pembuat Repot
Submitter Contact Number / Nombor Telefon Pembuat Report
*
Informer Contact Number / Nombor Telefon Pembuat Report
Submitter Position / Posisi Pembuat Repot
*
Please Select
Area Manager / Pengurus Kawasan
Operations Manager / Pengurus Operasi
For Office Use Only
To be update by OHSE Coordinator
Case Status
*
Please Select
OPEN
PENDING Response from OM/AM
PENDING MC Submission
PENDING JKPP
CLOSE
JKPP Submission Number
How Many MC Submitted
Please Select
One MC Submission
Two MC Submission
Three MC Submission
Please select from dropdown
UTD Loss of Working Days
MC Date 1st Submission - Start
-
Day
-
Month
Year
Please enter starting MC Date
MC Date 1st Submission - End
-
Day
-
Month
Year
Please enter ending MC Date
MC 1st Submission Photo Upload
Browse Files
Drag and drop files here
Choose a file
Only can accept file format pdf, jpg, jpeg, png, gif
Cancel
of
MC Date 2nd Submission - Start
-
Day
-
Month
Year
Please enter starting MC Date
MC Date 2nd Submission - End
-
Day
-
Month
Year
Please enter ending MC Date
MC 2nd Submission Photo Upload
Browse Files
Drag and drop files here
Choose a file
Only can accept file format pdf, jpg, jpeg, png, gif
Cancel
of
MC Date 3rd Submission - Start
-
Day
-
Month
Year
Please enter starting MC Date
MC Date 3rd Submission - End
-
Day
-
Month
Year
Please enter ending MC Date
MC 3rd Submission Photo Upload
Browse Files
Drag and drop files here
Choose a file
Only can accept file format pdf, jpg, jpeg, png, gif
Cancel
of
Back To Work Date
*
-
Day
-
Month
Year
1
Submit
Should be Empty: