DOLE/BWC/OHSD/IP-5

Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
BUREAU OF WORKING CONDITIONS
Manila
REPORT ON SAFETY ORGANIZATION
Date Filed _____________________
Regional Office No. XII
File Number ___________________
Name of Establishment _________________________________________________
Address _____________________________________________________________
Nature of Business ____________________________________________________
Persons Employed, including Management:
1st shift: Male _______ Female ________
2nd shift: Male _______ Female ________
3rd shift: Male _______ Female ________
TOTAL : Male _______ Female ________
A. Policy and Program on Safety and Health:

B. COMPOSITION OF SAFETY COMMITTEE:
Central Safety Committee
Name

Type: _______________

Position in Establishment

Chairman :
Secretary

:

Members

:

C. Technical Information:
a. Brief description of process operation and number and kind of equipm
ent.

Submitted by:
_______________________________
General Manager/Employer

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