Clause 30

any accident in a factory which —

causes loss of life to a person employed in the factory; or

disables any such person for more than three days from earning full wages at the work at which he was employed; or

causes any injury to any such person which requires such person to be detained in a hospital for at least twenty-four hours for observation or treatment; or

any dangerous occurrence (defined in the Act) taking place in a factory.III. PARTICULARS OF INJURED/DECEASEDName NRIC No.Address11 Address in Singapore. Marital statusAge SexRace OccupationWork Permit (if any) No. CitizenshipPeriod employed by present occupier/employer prior to accidentPeriod employed in present type of occupation prior to accidentTime the Injured/Deceased started work on the day of accidentExpected period of absenceIV. PARTICULARS OF ACCIDENT/DANGEROUS OCCURRENCEDate TimePlace Nature of InjuryDescription of machine involved, if anyDescription of Accident/Dangerous OccurrenceI hereby certify that the particulars given in this form and in the Appendix I are correct to the best of my knowledge.Date .................................................................... Signature of Occupier/EmployerTel. ..............................FOR OFFICIAL USE ONLYNote:—The person giving notice of an accident/dangerous occurrence should complete Appendix I by inserting a tick (√) in the appropriate boxes.APPENDIX ICLASSIFICATION OF ACCIDENT/DANGEROUS OCCURRENCEI. NATURE OF INJURY□ Abrasions □ Concussions and internal injuries □ Fracture□ Amputation □ Freezing□ Asphyxia □ Cuts □ Laceration□ Burns (Heat) □ Dislocation □ Multiple injuries□ Burns (Chemical) □ Effects of electric current □ Poisoning□ Bruises and contusions □ Puncture wound □ Effects of radiation □ Sprains and strains □ OthersII. PART OF BODY INJUREDHead and Neck Upper Extremities Body Lower Extremities □ Scalp □ Shoulder □ Back □ Hips □ Multiple locations□ Skull □ Upper arms □ Chest □ Thighs □ Eyes □ Abdomen □ Legs □ Ears □ Elbow □ Pelvis □ Knee □ Nose □ Forearm □ Groin □ Ankle □ Mouth □ Wrist □ Others □ Feet □ Teeth □ Hand □ Toes □ Face □ Palm □ Others □ Neck □ Fingers □ Others □ Others III. TYPE OF ACCIDENT/DANGEROUS OCCURRENCE□ Struck against objects □ Contact with temperature extremes□ Struck by sliding, falling, flying or other moving objects □ Exposure to or contact with electric current□ Caught in or between objects □ Exposure to or contact with harmful substances or radiations□ Fall or slip on same level □ Inhalation, absorption, ingestion, poisoning□ Fall to different level □ Drowning□ Overexertion □ OthersIV. AGENCY OF ACCIDENT/DANGEROUS OCCURRENCE□ Machines □ Floors or level surfaces□ Lifting equipment □ Ladders□ Transport equipment or vehicles □ Scaffolds and stagings□ Hand tools □ Stairs or steps□ Pressure vessels □ Explosive or inflammable substances□ Furnaces, ovens, kilns □ Poisonous substances□ Electrical equipment □ OthersAPPENDIX IICAUSE OF ACCIDENT/DANGEROUS OCCURRENCEI. HAZARDOUS CONDITION□ Absence of guard rails □ Absence of safety appliance□ Absence of safety guard □ Defective safety appliance□ Inadequate guarding □ Improper appliance or equipment□ Ineffective safety guard □ Ineffective protective equipment□ Safety guard not properly adjusted □ Improper clothing□ Faulty electrical installation □ Defective tools□ Unsafe electrical appliance □ Unsound structure□ Faulty machinery □ Improper illumination□ Unsafe design or construction □ Improper ventilation□ Poor housekeeping □ Unsafe place of work□ Hazardous arrangement □ Other hazardous conditionII. UNSAFE ACT□ Improper use of protective equipment □ Improper or unsafe lifting or carrying□ Failure to use personal protective equipment □ Unsafe climbing □ Unsafe driving□ Using improper or defective tools, equipment, vehicles or materials □ Riding on loads, forklifts or other lifting equipment□ Using tools, equipment, vehicles or materials unsafely □ Taking an unsafe position □ Tampering with machinery in motion□ Making safety devices inoperative or unsafe □ Operating without authority □ Operating at unsafe speed□ Tampering with equipment □ Working under suspended load□ By-passing safety devices □ Horseplay□ Wrong method of working or faulty operation □ Carelessness or recklessness □ Other unsafe act□ Unsafe loading, placing or mixing □ No unsafe actIII. CONTRIBUTING FACTORS□ Lack of knowledge or skill □ Lack of co-ordination□ Disregard of instructions □ No proper supervision□ Act of person other than injured □ Bodily defects□ Foul play □ Other contributing factors□ Fatigue TENTH SCHEDULESection 60(1).Notice of Patient Suffering from Industrial Diseases(This notice shall be completed by a registered medical practitioner attending on or called in to visit a patient whom he believes to be suffering from an industrial disease and forwarded to the Chief Inspector of Factories, Ministry of Labour, Havelock Road, Singapore 1).Name of PatientAgeSexRaceNRIC No.Residential AddressPresent OccupationName and Address of EmployerDiagnosisIf patient is deceased, state date of last attendanceName of DoctorLIST OF NOTIFIABLE INDUSTRIAL DISEASES: —Name and Address of Hospital/ClinicANILINE POISONINGANTHRAXARSENICAL POISONINGASBESTOSISTel. No.Doctor’s Ref. No.BERYLLIUM POISONING BYSSINOSISCADMIUM POISONINGCARBON BISULPHIDE POISONINGCHROME ULCERATIONCHRONIC BENZENE POISONINGCOMPRESSED AIR ILLNESSEPITHELIOMATOUS ULCERATION (due to tar, pitch, bitumen, mineral oil or paraffin or any composed product or residue of any such substance)INDUSTRIAL DERMATITISLEAD POISONINGMANGANESE POISONINGMERCURIAL POISONINGMESOTHELIOMANOISE INDUCED DEAFNESSPHOSPHOROUS POISONINGSILICOSISDateSignature of DoctorTOXIC ANAEMIATOXIC JAUNDICEELEVENTH SCHEDULESection 60(3).Notice of Patient Suffering from Industrial Diseases(This notice shall be completed by the occupier of factory pursuant to section 60(3) of the Factories Act, 1973, and forwarded to the Chief Inspector of Factories, Ministry of Labour, Havelock Road, Singapore 1).Name of OccupierOffice AddressFactory AddressNature of BusinessParticulars of patient who has contracted the industrial disease:LIST OF NOTIFIABLE INDUSTRIAL DISEASES: —ANILINE POISONINGNameANTHRAXARSENICAL POISONINGNRIC No.ASBESTOSISAddressBERYLLIUM POISONINGBYSSINOSISCADMIUM POISONINGSexAgeCARBON BISULPHIDE POISONINGCHROME ULCERATIONOccupationCHRONIC BENZENE POISONINGCOMPRESSED AIR ILLNESSEPITHELIOMATOUS ULCERATIONHow long employed prior to the date of contracting the industrial diseaseINDUSTRIAL DERMATITISLEAD POISONINGMANGANESE POISONINGName of industrial disease diagnosed by the doctorMERCURIAL POISONINGMESOTHELIOMANOISE INDUCED DEAFNESSPHOSPHOROUS POISONINGName of doctor who makes the diagnosisSILICOSISTOXIC ANAEMIATOXIC JAUNDICEName and Address of Hospital/Clinic DateSignature of Occupier of Factory.”.