Schedule “NINTH SCHEDULE

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