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Republic of the Philippines

Department of Labor and Employment


BUREAU OF WORKING CONDITIONS
Manila
EMPLOYERS 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
occurrences).

EMPLOYER
INJURED
OR ILL
PERSON
OCCUPATIONAL
HISTORY
ACCIDENT
OR ILLNESS

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14.
NATURE &
EXTENT OF
INJURY OR
ILLNESS
CAUSE OF
ACCIDENT
OR ILLNESS

PREVENTIVE
MEASURES

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Establishment: __________________________________
Address: ________Nature of Business: _______________
Name of Employer: __________Nationality: __________
No. of Employees: ___M: ___ F: ___Total: ____________
Name: __________Age: ____ Sex: ____Civil status: _____
Address: ________________________________________
Ave. Weekly wage: P ____ No. of dependents: __________
Length of service prior to accident or illness: ____________
Occupation: _______ Experience at occupation: _________
Work shift: ___1st ___2nd ___3rd ___Hours of work/day:___
Date of accident/ illness: ______________ Time: ________
The accident involved: _________ Personal Injury: ______
Property damage: _______________
Description of accident/ illness( give full details on how accidents /
illness occurred):__________________________________
________________________________________________
Was injured doing regular part of job at the time of accident
or illness: If not, Why? ___________
Extent of disability: _____fatal: ___permanent total: _____
permanent partial: _temporary total: ___med. treatment: __
Nature of injury or illness: ____ parts of body affected: ___
Date disability begun: ____ Date returned to work: ______
Days lost: __________ or days charged: _______________
The agency involved: _____________________________
The agency part involved: ___________________________
Accident type: ___________________________________
Unsafe mechanical or physical condition: ______________
The unsafe act : __________________________________
Contributing factor: _______________________________
Preventive measure (taken or recommended): ____________
Mechanical guards, personal protective equipment and other
safeguards provided: ________________________________

Batangas Business Office: BS-01 Dimatatac Road, San Pascual, Batangas, 2404, Philippines
Tel. No.: (043) 727-1026 / 727- 4926 / Tele-Fax No.: (043) 727-1964
Email Add: m4cmsi@yahoo.com / Website: www.m-4constructio.com

27.

MANPOWER 29.

MACHINERY
& TOOLS

MATERIALS

EQUIPMENT

Were all safeguards in use? _____ If not, why? ___________


_________________________________________________
28. Compensation: ___________________________________
Medical & hospitalization: _________________________
30. Burial: __________________________________________
31. Time lost on day of injury: __________________________
Hrs :____________ mins: _____________________
32. Time lost on subsequent days: ______Hrs: _____mins:____
(treatment or other reasons)
33. Time on light work or reduce output: _______day: _______
percent output: ________________
34. Damage to machinery & tools(describe): ________________
35. Cost of repair or-replacement: ________________________
P : ____________________________
36. Lost production time: ______________ cost: _____________
37. Damage to equipment( described): _____________________
38. Cost of repair or replacement: ________________________
P: _____________________________
39. Lost production time: _______________costs:_____________
40. Damage to equipment(described): _____________________
41. Cost of repair or replacement: ________________________
P: ____________________________
42. Lost production time: ______________costs:_____________

I HEREBY CERTIFY on my on honor to the accuracy of the foregoing information.


____________________________
Date
____________________________
Investigating Officer & Position

______________________
Employer

Batangas Business Office: BS-01 Dimatatac Road, San Pascual, Batangas, 2404, Philippines
Tel. No.: (043) 727-1026 / 727- 4926 / Tele-Fax No.: (043) 727-1964
Email Add: m4cmsi@yahoo.com / Website: www.m-4constructio.com