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DEPARTMENT OF OCCUPATIONAL SAFETY AND HEALTH

Website : http://www.dosh.gov.my

CHECKLIST FOR NEW REGISTRATION AS


SITE SAFETY SUPERVISOR (SSS)
Applications should be addressed to:
Director General,
Department of Occupational Safety and Health,
Level 2, 3 & 4, Block D3, Complex D,
Federal Government Administrative Centre,
62530 Federal Territory of Putrajaya.
(ATT: Director of Industrial Safety Division)

Name of applicant : ________________________


Phone No

: ________________________

Email

: _________________________

The following information is required (information should be in the order below): NO.

YES
()

ITEM

1.

A letter from the applicant's mailing address along with the latest
along with phone numbers and email addresses.

2.

Application Form (Form A) properly filled

3.
4.

NO
(X)

OFFICE USE

NOTE

Medical examination form (Form B) which has been completed by a


qualified medical doctor.
Two (2) recent driving license photographs.
Please write your name, N.R.I.C. No. and SHO posts in the
background. Clip on the top right corner of the form

5.

Copy of N.R.I.C.

6.

Copy of the transcript with diploma in engineering or architecture


or construction-related field; or
Certified copy of certificate courses and pass site safety supervisor
program.

7.

Letter of confirmation of current and previous employer stating the


period or date of experience involved in site safety supervision.

8.

Appointment letter / contract work as Site Safety Supervisor


personnel (during the involvement)

9.

10.

A complete duties list and acknowledged by the current and


previous employers
Employer company profile contains information such as type of
industry, number of employees, industry class under Rule
Occupational Safety and Health (Safety and Health Officer) in 1997,
and other information related

Departmental of Occupational Safety and Health

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DEPARTMENT OF OCCUPATIONAL SAFETY AND HEALTH


Website : http://www.dosh.gov.my
11.

Registration number of construction site with Dosh and factory


inspection reports / site construction / audit work (such as JKJ 17 or
audit report from the State DOSH).

12.

Copies of other certificates related to safety and health / other


documents required for the application

NOTE:

Documents that have been submitted cannot be returned.


For Office Use:
DS 001 No.
:
Receipt No.
:
Registration No. :
Receive Date
:
Office Stamp
:i.
Admin

___________________________________
___________________________________
___________________________________
___________________________________
ii . Industrial Safety Division

iii. PP Unit Head

For Officer Use (BKI):


Receive Date
Document
Note

: ________________________________
: Complete / Not Complete
:

Departmental of Occupational Safety and Health

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SSS

FORM A

Affix
Passport size

FACTORY AND MACHINERY ACT 1967


FACTORIES AND MACHINERY (BUILDING OPERATIONS AND WORKS
OF ENGINEERING CONSTRUCTION) (SAFETY) REGULATIONS, 1986
(Regulation 25(1))

1.0
1.1

PERSONAL PARTICULARS:
Name (in block letter):

1.2

Sex :

1.3
1.4

1.5

2.0

2.1

3.0

4.0

Male

Female

Place Of Birth:
Name and address of employer:

Home Address:

1.6

Date Of Birth:

1.7

Identity Card Number :

1.8
1.9
1.10
1.11

1.12

Citizenship:

Tel. No.

(Home):
(HP): .
Tel. No. (Office):

Fax. No. (Office):

Email: .......

EDUCATION AND EXPERINCES (Please attach photocopy of certificate/diploma/degree)


Name of Institution / University:
Year;
Level of Qualification:

to

to
to

Working Experience (Please attach a complete list of duties and is recognized by employers):
Position:

COURSES AND QUALIFICATION

Period of Employment

to
to
to
to

Employer:

DECLARATION
I hereby declare that the above particulars are true and correct to the best of my knowledge.
Signature

Signature

: ..

Date

: ...

N.R.I.C No.

: .

Name

31022013

Name of Witness
Date

: .
: .

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