DOLE/BWC/OHSD/1P-6
Republic of the Philippines
DEPARTMENT PF LABOR AND EMPLOYMENT
BUREAU OF WORKING CONDITIONS
Baguio City
EMPLOYER’S WORK ACCIDENT/ILLNESS REPORT
(This report shall be submitted by the employer for every accident or illness to the Regional Office having jurisdiction on or before the 20th day of the month following the date of occurrence.)
1. Establishment: ______
EMPLOYER 2. Address: ______Nature of Business:______
3. Name of Employer: ______Nationality: ______
4. No. of Employees: ______Male: ______Female: ______Total: ______
INJURED 5. Name: ______Age: _____ Sex _____ Civil Status:______
OR ILL 6. Address: ______
PERSON 7. Average Weekly Wage: P______No. of Dependents: ______
8. Length of service prior to accident or illness:
OCCUPATIONAL 9. Occupation: ______Experience at Occupation: ______
HISTORT 10.Work Shift:___1st____2nd____3rd___Hours of work/day:_____Day/Week___
11. Date of accident/Illness: ______Time: ______
12. The accident involved: ______Personal Injury ______
ACCIDENT Property Damage ______
OR 13. Description of accident/illness (Give full details on how accident/illness
ILLNESS occured):______
______
14. Was injured doing regular part of job at the time of accident or illness:
If not, why? ______
15. Extent of Disability: ____ Fatal ____ Permanent Total______
NATURE & Permanent Partial _____Temporary Total ____ Medical Treatment ___
EXTENT OF 16. Nature of Injury or Illness: ______Parts of Body Affected: ______
INJURY OR 17. Date Disability Begun: ______Date Returned to Work ______
ILLNESS 18. Days Lost: ______or Days Charged:______
19. The Agency Involved: ______
CAUSE OF 20. The Agency Part Involved:______
ACCIDENT 21. Accident Type: ______
OR ILLNESS 22. Unsafe Mechanical or Physical Condition: ______
23. The Unsafe Act: ______
24. Contributing Factor: ______
25. Preventive Measures (taken or recommended): ______
PREVENTIVE 26. Mechanical guards, personal protective equipment and other safeguards
MEASURES provided: ______
27. Were all safeguards in use? ______If not, why? ______
______
28. Compensation: ______P ______
29. Medical and Hospitalization: ______
30. Burial:______
MANPOWER 31. Time Lost on Day of Injury:______
32. Time Lost on Subsequent Days:______Hrs. ______Mins. ______
(treatment or other reasons)
33. Time on light work or reduced output: ______Day ______
Percent Output: ______
34. Damage to Machinery and Tools (Describe): ______
MACHINERY 35. Cost of repair or replacement: ______
AND TOOLS P______
36. Lost production Time: ______Cost:______
37. Damage to Materials (Describe):______
MATERIALS 38. Cost of repair or replacement: ______
P ______
39. Lost Production Time: ______Cost: ______
I HEREBY CERTIFY on my honor to the accuracy of the foregoing information.
______
Date
______
Investigating Officer & Position Employer