DOLE/BWC/OHSD/IP­5

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: Type: _______________

Central Safety Committee

Name Position in Establishment

Chairman :

Secretary :

Members :

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

Submitted by:

_______________________________
General Manager/Employer