DOLE/BWC/OHSD/OH-47 A

IMPORTANT NOTE:
Republic of the Philippines
Department of Labor and Employment
Data to be declared should be purely DCDC.
Bureau of Working Conditions
DCDC tradecons & owner side subcon are not
Occupational Health and Safety Division included.
This form is an older version than the blank
ANNUAL MEDICAL REPORT FORM form attached together with this sample. There
are some minor changes in the data of the latest
For Period January 1, 2018 to December 31, 2018
___________________________________________________________________________________

Official Name of
1. Name of Establishments: ABC Project
Dakay Construction and Development Corportion
2. Address: Address of Project _
3. Name of Manager/Owner: Name of Project Manager/Owner or Client
4. Nature of Business and Products/Service (Ex. Manufacturing, Textile)
Type of project
General Engineering _
5. Total Number of Employee: 151 Number of Shifts: 1
Total No. of employees
6. Number Distribution of Employees as to nature of workplace, sex, and work shift declared here should be the
Office Construction Site/Field same as what is declared in
st
1 Shift 2nd Shift_ 3rd Shift DOLE Annual Work
Illness/Accident Exposure
Male: 6 0 145 0
Female: 0 0 0 0
Total: 6 0 145 0
7. Preventive Occupational Health Services: (Check or Cross)
a. Occupational Health Services is organized/provided by:
( /) The establishment/undertaking
( ) Government authority/institution
( ) Other bodies/groups/institution (specify)
b. Occupational Health services as described under 8a above, is organized/provided as a service:
( /) Solely for the workers of the establishment/undertaking
( ) Common to a number of establishments/undertakings
c. The employer engages the services of:
(√) Occupational Health and Safety Consultant
Name: Mr. Bancal
Address: _
( /) Occupational Health & Safety Practitioner
Name: Roberto S. Delos Santos _
Address: Mabolo, Cebu City _
( ) Occupational health physician
Name: n/a _
Address: _
(/) Occupational health nurse
Name: Name of Nurse _
Address: ____________________________________________
d. The occupational health physician/practitioner /nurse/personnel conduct an inspection of the workplace:
( ) Once every month ( ) Once every three (3) months
( ) Once every two (2) months ( /) Twice a month
( /) Other details: General inspection is conducted twice a month but Safety
& Health personnel conduct regular health and safety inspections from time to time.
8. Emergency Occupational Health Services:
a. The employer provides a treatment room/medical clinic in the workplace with medicines and facilities:
(/) Yes ___________ ( ) No _______
( /) others, please specify: engagement of VSMMC Hospital as emergency medical facility
b. Schedule of attendance in the workplace:
Work shift
Occupational health physician: ____hrs/day
Occupational health practitioner: ____hrs/day
Occupational health nurse: _8_ hrs/day 8am - 5pm (Monday - Saturday)
c. Schedule of attendance of full-time first-aider:
( ) 1st workshift
(/) 2nd workshift
rd
( ) 3 workshift
d. The following occupational health personnel of this establishment have undergone training in occupational
health and safety/first-aid:
( ) Occupational health physician
( /) Occupational health nurse
( /) First-aider
( ) others, please specify ______________________________________
9. Occupational Health Services:
a. The occupational health personnel of this establishments conducts regular appraisal of the sanitation system
in the workplace:
 ( /)Yes ( ) No
b. Number of workers who underwent the following medical examination:
Physical Exam X-Ray Urinalysis
1. Pre-placement 26 26 26
2. Periodic 125 125 125
3. Return-to-work
4. Transfer Pls coordinate
5. Special with Ma'am
Jenelyn or Ma'am
6. Separation Unorlie (company
nurse) for the data
Stool Exams Blood Test Hep. B Screening required here
1. Pre-placement 26 26 26
2. Periodic 125 125 125
3. Return-to-work
4. Transfer
5. Special
6. Separation

10. Report of Diseases

Counting for number of
a. Number of cases diagnosed/treated for the following diseases (/of x):
cases for the disease will
MALE FEMALE TOTAL NUMBER
be per Person per illness
Skin:
(/) allergy 1 1 For Ex.
( ) dermatoses/dermatitis Person A asked for 2
medicines for allergy on
( ) infection as folliculitis/
Jan. 1, 2016 & asked for
abscess/paronychia the same medicine for
( ) others: Fever allergy on
Head: Dec. 1, 2016. - This
( ) migraine headache will count as ONE case
only
(/) tension headache 5 5
( ) others:
Eyes:
( ) error of refraction Person B asked for 2
( ) bacterial/viral conjunctivitis medicines for
hyperacidity & 1 for
( ) cataract allergy - The counting
( ) others will be:
Pterydium 1 case for allergy &
Hordeolom 1 case for hyperacidity
Mouth & ENT:
( ) gingivitis
( ) herpes labiales/externa
( ) otitis media/externa
( ) deafness
( ) meniere’s syndrome/vertigo
( /) rhinitis/colds 2 2
( ) nasal polyps
( ) sinusitis
( ) tonsillopharyngitis
( ) laryngitis
( ) Others
Respiratory:
( ) Bronchitis
( ) Bronchial Asthma
( ) Pneumonia
( /) Tuberculosis 3 3
( ) Pneumoconiosos
( ) Others:
Heart & Blood Vessel:
(/) Hypertension 2 2
( ) Hypotension
( ) Angina Pectoris
( ) Myocardial Infarction
( ) Vascular disturbance in extremities
due to continuous vibration
( ) Others
Heart Problem
Gastrointestinal:
( /) Gastroenteritis/Diarrhea 3 3
( ) Amoebiasis
( /) Gastritis/Hyperacidity 2 2
( ) Appendicitis
( ) Infectious Hepatitis
 ( ) Liver Cirrhosis
( ) Hepatic Absecess
( ) Cancer (Hepatic/Gastric)
( /) Others:
Stomachache 1 1
Genito-Urinary:
(/ ) Urinary Tract Infection 1 1
( ) Stones
( ) Cancer
( ) Others
Reproductive:
( ) Dysmenorrhea
( ) Infection (Cervicitis)
(Vaginitis)
( ) Abortion (Spontaneous)
(Threatened)
( ) Hyperemesis Gravidarum
( ) Uterine Tumors
( ) Cervical Polyp/Cancer
( ) Ovarian Cyst/Tumors
( ) Sexually-Transmitted
Diseases
( ) Hernia (Inguinal)
(Femoral)
( ) Others
Neuromuscular/Skeletal/Joints:
( ) Peripheral Neuritis
( ) Torticollis
( ) Arthritis
(/ ) Others
Musculoskeletal Spasm
Muscle pain 2 2
Lymphatics and Circulatory:
(/ ) Anemia 1 2
( ) Leukemia
( ) Cerebrovascular Accident
( ) Lymphadenitis
( ) Lymphoma
Infectious Diseases:
(/ ) Influenza 2 15
( ) Typhoid/Para-Typhoid Fever
( ) Cholera
( ) Measles
( ) Mumps
( ) Tetanus
( ) Malaria
( ) Schistosomiasis
( ) Herpes Zoster
( ) Chicken Pox
( ) German Measles
( ) Rabies
(/ ) Others
Cough 6 6
Diseases due to Physical Environment:
( ) Diseases due to abnormalities
in temperature & humidity
( ) Diseases due to abnormalities
in air pressure
( ) Poisoning/Overdosage
to chemicals
Total Number . . . . . . . . . . .
11. Report of Occupational Accidents/Injuries

Nature MALE FEMALE TOTAL NUMBER

Contusion, bruises, hematoma
Abrasions
Cuts, Lacerations, puncture 2 2 Total number should
Concussion coincide with the no.
Avulsion injuries declared in
Amputation, loss of body parts DOLE Annual Work
Crushing injuries Illness/ Accident
Exposure Data
 Illness/ Accident
Spinal injuries Exposure Data
Cranial injuries
Sprains 1 1
Dislocation/Fractures
Chemical Burns
Others:
12. Immunization Program (Indicate the number immunized)
Tetanus Toxoid Injection
Tetanus Antitoxin Injection
Tetanus Globulin Injection
Anti-Cholera, Anti-Typhoid
Triple vaccine
Others (Please specify)
Hep- B Vaccine (optional)
Flu Vaccine (optional) 3 3
13. Keeping of Medical-Records of Workers (Please check)
(√ ) done ( ) not done
14. Health Education and Counseling by Health and Safety Personnel:
(Please check one or more)
(√) done individually as each worker comes to the clinic for consultation.
(√) done in organized group discussions/seminars
(√) done with the use of visual displays and/or promotional materials, leaflets, etc.
15. Other Health Programs (Please check)
Seminar/ Use of Visual
Programs Counseling
Orientation Aid/Materials
HIV Awareness √ √
PTB Awareness √ Refer to the ff.:
(For 3 employees only 1. Toolbox Meetings
with positive result & Orientations
including
conducted w/ in the
referral/endorsement to
√ √ specialist) period coverage
Nutrition Program 2. Trainings/
√ Seminars attended
Family Planning Program √ √ √ 3. Bulletin Board post
Hepatitis-B & Leaflets
Awareness 4. Supp. Docs or
Procedures found in
IMS Manual
5. Consultation w/
√ √ nurses
Dangerous Drug Program √ √
Physical Fitness Program: (Please check)
Sports Activities ( /) Yes ( ) No Others could include excercise
conducted during Toolbox
Others (Please specify) ( ) Yes ( ) No meeting

16. Hazards in the Workplace: (Please check and give details of the active substance)
a. Chemical Hazards:
( /) dust (Ex. Silica dust)
( ) liquids (Ex. Mercury)
( /) mist/fumes/vapors
(Ex. Mist from paint spraying)
( ) gas (Ex. Co, H2S)
( ) others (please specify)
b. Physical Hazards:
( / ) Noise
( / ) temperature/humidity
( ) illumination
( / ) radiation/ultraviolet/
Microwave
( / ) others (please specify)
b. Biological Hazards:
( ) viral
( ) bacterial
( ) fungal
( ) parasitic
( ) others
Substance and/or Number of Average no. of workers
Sources Workers Exposed exposed (Estimate Only)
2 In determining the no. of
grinding/cutting operations workers exposed, consider
the actual situation.
2 For Ex.
welding fumes (welders) Static/monotonous work
(prolonged sitting) -
Who are the workers & how
many of them are doing
static/monotonous work
moving vehicles, cutting, (for ex. proloned sitting)
welding, and grinding 10 everyday for long period of
operations (laborers, welders) hours that it is already
sun rays, welding 7 hazardous or unhealthy &
operations (laborers, welders) that it can possibly cause
damage to his body/health
welding, cutting and 3
grinding operations (laborers, welders)
hand drill tools, moving 5
or lifting vehicles (drivers, operators)
 c. Ergonomic Stress:
Manual lifting of heavy
( /) Exhausting physical work materials 5 (laborers)
( ) Prolonged Standing
Improper bending &
(/ ) Low Back Pain lifting 10 (laborers)
( ) Unfavorable work posture
(/) Static/monotonous work Prolonged sitting 2 (operators)
( ) Others, specify

Date: _____ _

Prepared by:

___________ ___________
Nurse Safety Compliance Officer

Noted by:

_______________
Project Manager