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N 2004 Part A1 Part A2 Notifier - Regulation 7(1) Employer Notifier - Regulation 7(2) Registered Medical Practitioner (If more than one person please use separate form) Name Name Designation Designation Name & Address of Organisation Address of Clinic / Hospital Contact Number Contact Number R.O.C. No JKKP Reg. No Industrial Classification Code (Table 3) Contact person (if different from above) Part B - Affected Person Part C - Occupational Poisoning / Disease Name Diagnosis.

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  • 2004
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  • disclaimer
  • designation
  • notification
  • classification
  • PROVISIONAL
  • Nationality
  • Practitioner
  • completing
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  • MALAYSIA
  • Occupational
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