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DEPARTMENT OFLABOR AND EMPLOYMENT Bureau of Working Conditions

Intramuros, Manila

CHECKUSTOF DOCUMENTARY
REQUIREMENTS ON ACCREDITAlON OF OSH PRACTITIONER/CONSULTANT Approvedby: DirectorTERESITA R.MANZALA, CESOIII

DOLE-BWC-AF-CHK-PC
Revision Code: 0803-0 Page 1 of 1 Effectivity Date: August 2003

Prepared by: OHSD-SPIS INSTRUCTION: To the applicant

-Pleasefasten all attachments/documents neatly in a long plain folder and arranged according to the

following order enumerated below. Application may be submitted directly to BWe or to concerned R.O. Documents submitted must be signed in all pages. To DOLE receiving personnel. Please (V) or (X) mark in the appropriate column below when receiving application. Appticatlon with Incomplete documents shall be returned to the applicant together with this checklist indicating requirements for compliance. Name of Applicant: as:U

OSHPractitioner U CHECKLIST

OSHConsultant
Submitted Remarks

DOCUMENTARY

REQUIREMENTS

New Applicants:
1. 2. 3. 4. Two (2) copies of duly accomplished Application Form (DOLE-BWC-AF-PCN-Al ) with 2 copies most recent 1 x 1 ID picture signed at the back. (red background for SP, blue backQroundfor SC). Original Certificate of Employment indicating name, position and date of appointment at DresentDositionusina the offidalletterhead of the COmDany. Original of actual Duties and Responsibilitiesat present position, signed by immediate supervisor and Personnel Manager or authorized offidal of the company, using letterhead of the company. Photocopyof certificate of employment from previous employer/s indicating position(s) and date(s) of appointment (if any and necessary in support of actual experience on OSH). May submit actual functions and Droofof accomDlishmentsduly certified by the emDloyer. Photocopy of certificate of completion of the BureauPrescribed Course (4o-hr or 8o-hr)on OccuDational SafetYand Health issued by accredited STO. Photocopy of certificate of attendance/partidpation on other OSH related trainings / seminars/activities. Photocopyof CollegeDiplomaor Transcript of Records and Board Exam Certificateor PRC

YES NO

5.
6. 7.

_ _ _

8.

Ucense(ifany).

Proof/s of accomplishment or participation in OSH accident reports safety inspection/audit reports HSC committee report aSH program prepared/ implemented Other reports prepared by the applicant, please specify

__

_ _ _

accomplished Application Form (DOLE-BWC-AF-PCN-A2) with 2 copies most recent 1 x 1 ID picture signed at the back. (red background for SP, blue backaround for sct 2. Summary of Applicant's Accomplishments as OSH Practitioner / Consultant related to aSH signed by the employer and supervisor using official letterhead of the company. Consultant with more than one client- establishments shall submit an accomplishment report certified by the client's. 4. Photocopy of Certificate of Accreditation (last issued). 5. Photocopy of other aSH related trainings/seminars attended after last renewal of at least 16 hours per year or 48 hours of trainings for 3 years, earned from DOLErecognized/accredited STO/institutions authorized by law. 6. Proof/s of accomplishment or participation in OSH accident reports safety inspectionreports safety audit reports HSC committee report aSH program prepared/ Implemented Other reports prepared by the applicant, please specify When There Is if Chifnae of EmDlover/Dosition

Renewal of Accreditation: 1. Two (2) copies of duly

__

7. OriginalCertificateof Employmentindicatingname, positionand date of appointment at present DOsitionusina offidal letterhead of the company. 8. Originalof actual Dutiesand Responsibilities at present position, using offidalletterhead of the company, signed by immediatesupervisor and Personnel Manaaer or authorized officialof the comcanv. INITIAL EVALUATION / REMARKS:

_ _
_

Note: Originals
stated

will be required

for if

Complete documents submitted, signed In all pages. With incomplete documents, for compliance of the above

presentation during interviewif new

applicant; during filing of application

defidendes with mark "x:'.

Forinterview on Othe, specify

at

. pleasecall5273483 or 5275496.

renewal.

Checked

/ Receivedby:

Date/Time: 20

__

?~\.

DEPARTMENTOF LABORAND EMPLOYME Bureau of WorIdngConditions L'

Occupational Health and Safety Division

"'.!:A.

lIT

DOLE-BWC AF-PCN-Al
Revision Code: 0803-0

Page 1 of 3 Instructions:
Fill in all the data needed. Use block/printed letters or use a typewriter. Applicable. Please sign in all pages of the form. Write N.A. if the blanks are not

Please attach your 1" x 1" picture SC: blue background SP: red background 2 COPIES signed at the back

I would like to apply for Accreditation as:

o o
Sex: OM

aSH Consultant

aSH Practitioner

1. PROFILE
Last ,Na~e First Name Mlddli!Name
<:bilStatus:

o F

U Single
Married Otizenshlp: Religion: TIN No. :

o o

Widower/Widow Separated

City Address

(Number

& Street,

Town/City,

Province,

Zip Code)

Date of Birth:

Height:
HDme/Provincial Address

Weight:
Blood Type:

PRC No.(if any):

Business Address

SSS/GSIS No. Home No.:

Cellular

Phone

No (if any): Co. Tel No.:

Nature of Business

I Specific Productl Type of Service:

E-mail:
Employment Size:

Fax No.: MALE:

Workplace: PSIC Code:

Hazardous

Non-hazardous

FEMALE:

TOTAL:

Region:

GEO Code:

Zip Code:

Degree/units

Eamed

Inclusive dates

Awards/ Honors

Type of Professional Ucense received:

PRC Ucense NO.: Date Issued:

Validitv:

24
To be accomplished in duplicate

Note: This form is NOT FOR SALE. It may be reproduced

Jt:.

<1'.

DEPAJrnoIENT OFlABORANDEMPlOYMENT Occupational Health andSafety DivIsion r-

Bureau ofWcrlcJng Conditions

DOLE-BWC

OSH PRACTITIONER/CONSULTANT APPLICATION FORM (New Applicant)

AF-PCN-Al
RevisionCode: 0803-0 Page 2 of 3

4. aSH RELATED TRAININGS' SEMINARS ATTENDED ( As Participant) -, (Use additionalsheet if necessary) Please attachphotocopy of certificate. Originalcopies of certificates to be presented to authorized DOLEstaff for certification. Title (Start from recent to previous) Time' Duration To From No. of Hours Conducted by Venue

5. aSH RELATED LECTURES' SEMINARS fTRAININGS CONDUCTED ( As Resource Speaker) additionalsheet ifnecessary ) Please attach Dhotocopv of certificate/recoanition received. o. of Ct>f\u<;:,{ Time' Duration Hours TitlefTopic From To (Start from recent to previous)
iJ'f

(Use
V(t{{

6. aSH SKILLS' EXPERTISE' SPECIALIZATION ACQUIRED (Useadditional sheetif necessary) Trade' Occupation Field of Expertise Brief Description Years of
EXDerience

7.

aSH AWARDS' ACHIEVEMENTS 'RECOGNITION photocopy of certificate of award/recognition Title

RECEIVED (Use additional sheet if necessary). Attach

Issued by

Date Issued

25
To be accomplished in duplicate Note: This form is NOT FOR SALE. It may be reproduced

DEPARTMENT OF lABOR AND EMPI.OYM

Bu"eauof Wor1dng COnditions OcOJpatIonal_Ith and Safety Division

Ii:

OSH PRACTITIONER/CONSULTANT

DOLE-BWC

APPLICATION FORM
(New Applicant)

AF-PCN-Al
Revision Code: 0803-0

Page 3 of 3

8. OSH EXAMINATIONS' ELIGIBILITIES PASSED (if any) (Useadditional sheetif necessary). Pleaseattach
DhotocoDvof ID, license or certification

Title

Year Taken

Given bv

Ratina

9. MEMBERSHIPS' AFFILIATIONS RELATED TO OSH

OrQanization'Institution' AQency DesiQnation, Position Validitv

10. CHARACTER REFERENCES (give at least 3) Name Position I Occupation Companv I Address Contact Numberls

Do you have any pending a) administrative case If you have any, give details of the offense

DYes

D No b) criminal case?

DYes

No

Have you been convicted of any crime or violation of any law, decree, ordinance or regulations by any court or tribunal? DYes

No

If yes, give details DYes D No

Have you ever been convicted of any administrative offense? If your answer is "YES", give details of the offense

Have you ever been retired, forced to resign or dropped from employment in the public and private sector? DYes

No

If yes, give reasons

I certify that the information stated above are true and correct. Date: SIGNATURE RIGTH THUMB MARK

26
To be accomplished in duplicate

Note: This form is NOT FOR SALE. It may he reproduced