Department of Labor and Employment: Republic of The Philippines Intramuros, Manila

Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT

Intramuros, Manila
Certificate Number: AJA15-0048
ESTABLISHMENT REPORT ON COVID-19
_______________________________________
(Region-PO/FO-Year-Month-Count)
Instructions:
1. Accomplish this form in two copies when filing a notice of: a) Flexible Work Arrangement or b) Temporary Closure.
The report is considered as duly filed when the complete list of workers affected is made part of the submission.
Fields with asterisks (*) should be accomplished by the company representative for COVID-19 Adjustment Measures
Program applications.
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2. This form should be submitted to the DOLE Regional/Provincial/Field Office as soon as possible.
3. Page 1 should contain general information about the establishment and the number of workers affected.
4. Page 2 should enumerate the names of workers affected, their addresses and contact numbers, position title and
salary.
5. Total number of workers listed should equal the total number of workers affected as reported in this page.
A. Establishment Data
Name of Establishment*: (Please indicate registered name as reflected in the business permit)
Floor/Bldg/No
/Street/Subdi
vision*:
Barangay/Cit
y/Municipality
*:
Kind of
Business/Eco
nomic
Activity/Princi
pal Product:
Number of Ma Man
Workers*: le: ageri
al
Emp
loye
es:
Fe The report is considered as duly filed when the complete list of workers Sup
ma affected is made part of the submission. Fields with asterisks (*) should be ervis
le: accomplished by the company representative for COVID-19 Adjustment ory:
Measures Program applications.
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The report is considered as duly filed when the complete list of workers
affected is made part of the submission. Fields with asterisks (*) should be
accomplished by the company representative for COVID-19 Adjustment
Intramuros, Manila
The report is considered as duly filed when the complete list of workers Certificate Number: AJA15-0048
Intramuros, Manila
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Intramuros, Manila
Intramuros, Manila
Adsfsadjflsadkfjsda;lkfjsda;lkfjds;lkfjsc;oivjwarogvuhwgp;vouewho;sfgv;wei Certificate Number: AJA15-0048
Intramuros, Manila
Intramuros, Manila
accomplished by the company representative for COVID-19 Adjustment Certificate Number: AJA15-0048
Intramuros, Manila
affected is made part of the submission. Fields with asterisks (*) should beNumber: AJA15-0048
Certificate
Intramuros, Manila
The report is considered as duly filed when the complete list of workers Certificate Number: AJA15-0048
Intramuros, Manila
kfjsa;fijdsaf;ijsv;pwfjes;kjf;sklfjvd;skvjds Certificate Number: AJA15-0048
Intramuros, Manila
To Ran
tal k
: and
File:
Tota
l:
Date of
Filing*:
(mm/dd/yyyy)
B. Summary of Affected Workers due to

B.1 Flexible Work Arrangement*
Type of Flexible Work Arrangement
No. of Workers Effectivity Date
to be Implemented
Covered/Affected (mm/dd/yyyy)
(Use code below, select only one)
Codes for Flexible Work Arrangement Scheme:

 RW - Reduction of Workdays  FL - Forced Leave
 RE - Rotation of Employees  OTH - Others (Specify) ____________
B.2 Temporary Closure*

No. of Workers Effectivity Date Main Reason of Temporary Closure
Covered/Affected (mm/dd/yyyy) (Use code below, select only one)
Codes for Main Reason for Temporary Closure:

 LM - Lack of Market/Slump in Demand  I - Infection (COVID-19)
 LRM - Lack of Raw Materials  OTH - Others (Specify) ____________
CERTIFICATION
This is to certify as to the accuracy of the data provided in this report.
Name and Signature of Owner/Company Representative*:
Designation: Fax No.:
Contact No.: Email Address:
FOR DOLE (Regional/Provincial/Field Office) USE ONLY:

Updates/Remarks, if any:
Received/Verified by: a) Provision of assistance (please specify)
________________________________________________
b) Estimated date of resumption of normal business operations:
______________________________________ ________________________________________________
Name and Signature of DOLE Representative c) Others (please specify)
________________________________________________
Name and Signature of DOLE Representative:
Date: ______________
Date: ______________
LIST OF AFFECTED WORKERS DUE TO COVID-19
Instructions: If necessary, use additional sheets following the same format.

Intramuros, Manila
Profile of Affected Workers
Employment
No Name of Worker* Contact Status
Age* Sex* Home Address* Designation Salary1
. (Last Name, First Name, M.I.) Number* (regular,
contractual, etc.)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
1
Indicate whether per hour, per day or per month
* Mandatory fields to be accomplished by the company representative for COVID-19 AMP applications.

Department of Labor and Employment: Republic of The Philippines Intramuros, Manila

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Department of Labor and Employment: Republic of The Philippines Intramuros, Manila

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Copyright:

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Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

B. Summary of Affected Workers due to

Codes for Flexible Work Arrangement Scheme:

B.2 Temporary Closure*

Codes for Main Reason for Temporary Closure:

Designation: Fax No.:

Contact No.: Email Address:

FOR DOLE (Regional/Provincial/Field Office) USE ONLY:

LIST OF AFFECTED WORKERS DUE TO COVID-19

Instructions: If necessary, use additional sheets following the same format.

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