MSOSH OCCUPATIONAL SAFETY AND HEALTH AWARD 2018 APPLICATION FORM
Email address *
*PLEASE FILL IN EMAIL ADDRESS OF CONTACT PERSON
BRIEFING SESSION
A one day briefing will be conducted on four dates 14th December 2018 , 22nd December 2018 , 11th January 2019 and 19th January 2019 (Bonus marks are offered to those who attend the briefing). Your company representative are invited to attend and choose any one of the listed dates. Please register https://goo.gl/wPUxVZ
SECTION 1
REGISTRATION ONLINE
1) Applicant can register online by completing this form in MSOSH WEBSITE. Do NOT attach any document during registration
2) You can register online by this link http://bit.ly/2Dkas0A . Bonus mark will be give for Online Registration
3) Audit document must be sent separately to MSOSH Office. (See details below)
4) Closing date for online registration and document submission is on Monday, 11th February 2019. (Request for late submission please see item No.2 (page 2) Terms and Conditions from the link http://bit.ly/2B3pwht
DOCUMENT SUBMISSION
1) Please print Application Form and have it signed by the CEO/MD/GM, complete with company stamp.
2) Please attach all required documents either hard copy or soft copy, arranged systematically with label or index.
3) The printed Application Form together with requested supporting document (hard copy or soft copy) must be sent to MSOSH Secretariat by the closing date Monday, 11th February 2019.
4) Link of hard copy Application Form : http://bit.ly/2OGHPwE
Terms & Conditions *
Required
Particulars of Company/Organization
Name of Company: *
SOCSO Code No : *
Postal Address - Line 1 : *
Postal Address - Line 2 :
Postcode & City: *
State: *
Telephone No. : *
Fax No. :
ID. No :
(For Office Use, Leave Blank)*
Name of site to be audited: *
Address of Site - Line 1: *
Address of Site - Line 2 :
Postcode & City: *
State: *
Upload Address of Site:
(Please attach route map-if necessary, email to OSHAward.msosh@gmail.com OR upload here)
Site Contact Person: *
Designation:
E-mail: *
Tel No. : *
H/p No. : *
Fax No. :
Business Sectors: *
Only applicable to Construction & Engineering Construction Sectors:
(if the progress is below 20% or above 90% the organization is not eligible to participate.)
No. of Employees *
( Include Contract Employee & Permanent Contractors )
Particulars of chief Executive Officer & Person Submitting The Entry Form
Name of person submitting the form: *
Position of person submitting the form: *
Tel. no of person submitting the form: *
Fax. no of person submitting the form:
Signature & Stamp
Contact Person :
(Not applicable if same person submitting the form)
Position of contact person:
(Not applicable if same person who submit the form)
Email of contact person:
(Not applicable if same person who submit the form)
Tel no. of contact person:
(Not applicable if same person who submit the form)
Fax no. of contact person:
(Not applicable if same person who submit the form)
Name of Chief Executive Officer/ Managing Director / General Manager: *
Designation: *
Signature & Stamp
Please print Application Form and have it signed by the CEO/MD/GM, complete with company stamp.*
Category of Awards
Category to apply: *
Based on the criteria on page 3 (http://bit.ly/2QEy043), PLEASE TICK ONE CATEGORY YOU WISH TO APPLY:
NOTES: please attach supporting document to support qualification for category applied (PLATINUM & GRAND)
Application Fee
(A) Category Applied *
(B) Additional Fee *
Offshore Facilities only
(C) Written REPORT per site *
Optional
(D) Additional East M’sia *
(E) Total Fee *
(E) = (A) + (B) + (C) + (D)
Cheque No:
Payment should be made payable to : “Malaysian Society for Occupational Safety and Health”Account No.: 8002324462 CIMB Bank Berhad, Section 52, Petaling Jaya, Selangor.
Invoice
First Time Participant of MSOSH OSH Award
First time participant *
If NOT a first time participant
Please indicate latest year of award
If NOT a first time participant
Please indicate latest achievement of award
Others ( Optional )
GPS coordinate of the site to be audited:
Recommended site for auditor accommodation (<RM250):
Need Government Security clearance/ Work Permit?
Work Permit
Airport nearest to site:
Other logistics advice (if any)
OSH Performance Measurement
Please provide the following information
1. 2018 OSH Performance
a) Total man-hours worked accumulated in 2018: *
b) Average number if Staff & Permanent Contractor employed in 2018: *
c) Number of dangerous occurence/s: *
d) Total no of fatalities: (if any)
e) Total no. of LTI cases in 2018: (if any)
f) Total no. of days away from work in 2018: (if any)
g) Latest LTI was on: (If any)
(date)
MM
/
DD
/
YYYY
h) LTI frequency rate:
i) LTI severity rate: (if any)
2. 2017 OSH Perfomance (Applicable for PLATINUM & GRAND AWARD applicants only)
a) Total man-hours worked accumulated in 2017:
b) Average number of staff & contractors employed in 2017:
c) Total fatality:
d) Last fatality date: (if any)
MM
/
DD
/
YYYY
e) Last LTI was on: (if any)
MM
/
DD
/
YYYY
f) Last dangerous occurrence was on: (if any)
MM
/
DD
/
YYYY
NOTES*
1) Please click "NEXT" .
2) Continue with the next section until end.
3) Click "SUBMIT".
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