Dosh Form
Dosh Form
Dosh Form
REPUBLIC OF KENYA
DIRECTORATE OF OCCUPATIONAL SAFETY AND HEALTH SERVICES
NOTICE BY EMPLOYER OF AN OCCUPATIONAL ACCIDENT/DISEASE OF AN EMPLOYEE
PART 1
1. Employer/Occupier Particulars:-
ii. Name of Employer/Occupier……………………………….…………..……………………………………….………………
iii. WIBA* registration No………………………………….…OSHA* Registration No. …………………………………………
iv. Full Address P. O. Box……………………………………Physical Location…...……….…………………..……………….
v. E- Mail address……………………………………………………………… Tel…………………………..…………………
vi. Nature of Work ………………………………………………………………………………………………..….…………….
vii. Name and address of Insurance Company which has insured employee against accident
…………………………………………………………………………………………………….……………………..…
………………………………………………………………………………………………………………..………………
2. The Injured/sick employee’s particulars :-
i. Name……………………………………………………………………………………………………….………………
ii. Sex…………………………………………………………………………………………………………………………
iii. Age………………………………………………………………………………………………………..………..………
iv. Occupation …………………………………………………………………………...……………………………………
v. Full Address……………………………………… ……………………………………….……… ……………………..
vi. E- Mail address………………………………………………………………Tel: ………………..………………………
vii. Identity Card No. *(Incase of fatal injury, Death Certificate No.)………………………………………………….……
viii. Home District: …………………… Division: …………………Location: ………………Sub-location ………………..
3. Occupational Accident
i. Date of Accident …………………………… Time: ………………………Fatal /Non fatal …………………...…..
ii. Has the worker resumed working Yes/No ……………………………..Date of resumption ……………………...…..
iii. Place where accident took place…………………………………………………………………………………………..
iv. What is the injured worker’s Occupation…………………………………………………………………….…….……..
v. What duties was the employee undertaking at the time of the accident? ………………………………………..….…..
vi. Length of service with the present employer……………………………………………………………………….……..
vii. What work is the worker employed to undertake…………………………………………………………………….…..
viii. Cause of Injury……………………………………………………………………………………………………..……..
ix. Type of Injury ……………………………………………………………………………………………………..……..
x. Part of Body Injured………………………………………………………………………………………………..……..
4. Occupational Disease
Detail about the Occupational disease affecting the employee.
i. Date of diagnosis of the occupational disease …………………………………………………………………….………
ii. Name of medical practitioner who made the diagnosis ……………………………………………..……………………
iii. Date the employer was notified of the disease by the employee or medical practitioners….……………….……………
iv. Describe the Cause of the occupational disease ……………………………………………………………….…………
…………………………………………………………..…………………………………………………………………
……………………………………………………………………………………………………………………………..
5. Total Monthly earning at the date of the Accident/disease:-
Salary/wage .. .. .. .. .. .. .. .. Sh. ………………..………………
.
Total earnings paid to the employee during the period of incapacity .. .. .. Sh…………………………………
Station………………………………………………..……….. Date……………………………………………….
………… …..…………………………………
Occupational Health and Safety Officer
*Delete whichever is inapplicable