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Incident Report Form

Use this form to report accidents, injuries or medical situations incidents. If possible, the report should be completed within
24 hours of the event. Submit completed forms to the Office.
INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT
Full Name: MAH MUDDIN BIN AMIN
Home Address:
24E, Jalan Seremban Jaya, Taman Bukit Berlian,

70200, Seremban, Negeri Sembilan.


Director Employee Visitor Vendor
X
Phone Numbers Home Cell Work
0125423671 0685216477 0688881717

INFORMATION ABOUT THE INCIDENT


Date of Time Police Notified Yes No
15 FEBRUARY 2009 01:30 PM
Incident
Location of Incident
DIAMOND RESTAURANT

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
(attached additional sheets if necessary)

At 12.00 pm, I was received a call from the restaurants guard informed that my restaurant burned. At 12.30pm,
I arrived and found the firefighters are trying to put out the fire. After the fire was extinguished, it was found
that the kitchen fire caused major damage to the entire restaurant and required major equipment purchased
and interior repairs. This report are forwarded to the Bukit Berlian Fire Department.

Were there any witnesses to the incident? Yes No


If yes, attach separate sheet with names, addresses, and phone numbers.
Was the individual injured? If so, describe the injury (laceration, sprain, etc.), the part of body injured, and any other
information known about the resulting injury (ies).

There is no individual injured since the incident happen after restaurant closed.

Was medical treatment provided? Yes No Refused


If yes, where was treatment provided: on site Urgent Care Emergency Room Other

REPORTER INFORMATION
Individual Submitting Report (print name) MAH MUDDIN BIN AMIN

Signature

Date Report Completed: 15 FEBRUARY 2009


Names Addresses Phone no
Muhammad Shahruzi N083, Jalan Seremban Jaya, Taman Berlian, 013-2589541
70200, Seremban, Negeri Sembilan
Muhammad Nur Aiman N019, Jalan SSJ, Taman Tuanku Jaafar, 70200, 012-4445247
Seremban, Negeri Sembilan
Muhammad Nur Hafiz N045, Jalan Senawang, Taman Manis, 70200, 014-2598235
Seremban, Negeri Sembilan

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