Professional Documents
Culture Documents
The purpose of the WAIR is to allow the DOLE to determine root cause and allow investigation into possible solutions to
workplace accidents lowering the financial and time cost to both the worker and employer. Please fill in all fields as completely
as possible. Visitors / guests to the workplace shall be categorized under "worker" for the purpose of the WAIR.
1
2 3
4
5
6
7
8
9
10 11
12
13 14 15
16
17
18
19
20
21
22
23
1 If yes, then report to DOLE Regional Office using the DOLE-BQF-ALERT Form manually or online. Have the filled-in form ready
for the labor inspector. Contents of form may be relayed over phone if this would facilitate the speed of communicating the event
to DOLE.
2 Put an X if with or without Dangerous Occurrence
3 Refer to Reference Coding List D1-D18
4 Indicate if DOLE was notified within 24 hours (as noted in Item #1)
5 Put an X on the action taken by the Safety Officer.
6 Put an X where accident happened. Leave blank if not in given choices. Indicate location in the narration of the accident
7 Trade name of the business if different than the registered business name
8 SEC or DTI registered address of establishment.
9 SEC or DTI registered business name that hired and pays the wage/s of the involved worker
10 Refer to Reference Coding List Philippine Standard Industrial Classification, 2009
11 SEC or DTI registered business Owner/President/CEO/Chair
12 List number legally male and female workers hired and paid wages by the business (9) regardless of nature of employment
13 Date accident happened in Year, month, and day (Ex. 2019 Jan 01)
14 Time accident happened in 12 hour format (Ex. 10:00 AM, 11:30 PM)
15 Refer to Reference Coding list C1 to C9.2
16 Put an X on the appropriate answer
17 Describe all safety hazards present. Attach additional sheets as necessary.
18 Put an X on the appropriate answer
19 Describe all health hazards present. Attach additional sheets as necessary.
20 Describe other aggravating factors that may have aggravated the accident not previously described.
21 List materials and equipment that are primarily involved in the accident
22 Indicate time of start and end of shift and mark an X if AM or PM
23 Narrative of events leading to the accident. Attach pictures of the accident if available.
26
27
28 29 30
31
32
33
26 and 27 - Indicate if with machine damage and approximate total cost of the accident.
28 Indicate as DD/Month/YY (01 Jan 2018)
29 Indicate as HH:MM AM/PM (12:00 PM)
30 Refer to Reference Coding List C1-C16
31 Indicate the start time (HH:MM AM/PM) and end time (HH:MM AM/PM) of the worker's shift
32 Narrate events leading to the accident
33 Signature of the injured worker or employee's representative testifying that the narrative is correct.
44
45
46
47
34 Indicate what part of the body is affected. Photos may be attached as hard copy or picture files.
35 Put an X on the side affected
36 Mark with an X the type of disability incurred by injured worker as determined by the attending physician, OH personnel or
trained safety officer (RULE 1051)
Permanent Total Disability shall mean any injury or sickness other than death which permanently and totally
incapacitates an employee from engaging in any gainful occupation or which results in the loss or the complete loss of use of
any of the following in any of the following accident: (a) both eyes; (b) one eye and one hand, or arm, or leg or foot; (c) any
two of the following not in the same limb, hand, arm, foot, leg; (d) permanent complete paralysis of two limbs; (e) brain injury
resulting in incurable imbecility or insanity.
Permanent Partial Disability shall mean any injury other than death or permanent total disability, which results in the loss or
loss of use of any member or part of a member of the body regardless of any pre-existing disability of the injured member or
impaired body function.
Temporary Total Disability shall mean any injury or illness which does not result in death or permanent total or permanent
partial disability but which results in disability from work for a day or more.
37 Date (DD/MM/YYYY) when injured worker actually returned to work. Mark with ongoing if worker has not returned to work
at time of WAIR submission. A supplemental report on the worker status must be submitted upon return of the worker or if
there is final disposition of the worker.
38 List equipment or materials that are involved in the accident.
39 Refer to Reference Coding List C1-C9.2
40 Mark with an X all the hazards present at the time of the accident. Mark none if no safety hazard is present.
Unsafe Act and Condition as defined in the OSHC, Accident causes and Preventions
Unsafe Act - The human action that departs from a standard job procedure or safe practice, safety regulations or
instructions.
Examples: · Operating Equipment without Authority · improper PPEs or Using PPEs improperly
· Disregard of SOP or instructions · Horseplay
· Removing Safety Devices · Working in an unsafe posture
· Using Defective equipment · Willful intent to injure
Unsafe Condition - The physical or chemical property of a material, machine or the environment which could result in injury
to a person, damage or destruction to property or other forms of losses.
Examples: · Wet slippery floors · Live conductors without insulation
· Unstable stacking of materials · Equipment without machine guarding
· Protruding re-bars · Poor storage of combustible materials
41 Describe how the unsafe act or unsafe condition contributed to the accident.
42 Mark with an X all the hazards present at the time of the accident. Mark none if no health hazard is present.
Health Hazard Where a worker is liable to be exposed to any chemical, physical or biological hazard to such an extent as
ILO, Safety and Health in is liable to be dangerous to health, appropriate preventive measures shall be taken against such exposure.
Construction Convention,
1988
43 Describe how the health hazard aggravates or contributes to the accident.
44 Factors that may have an effect on the accident but not directly involved in the accident. (Eg: Medication intake, etc.)
45 Action done to address the injured and decrease or remove the hazards
46 Steps taken to prevent the recurrence of the same or a similar accident
47 Projected date when corrective measure will be in place and functional.
49
50
51 52
53
49 If with capability, images of the accident before and after placing of the corrective measures may be included in the report. If
the corrective measure is not in place by WAIR submission date, then corrective measure will be part of what will be
inspected by the labor inspector.
50 Name and signature of safety officer verifying that the corrective measures are physically in place. Write N/A if the corrective
measure is not in place by WAIR submission.
51 OH personnel or safety officer that conducted the investigation and filled in part of the report
52 Employer or representative that supplied part of the report
53 Date the Accident Investigation was done.
We hereby certify that the information above is accurate to the best of our knowledge. We understand that data
contained herein is compliant to RA 11469 Bayanihan to Heal as One Act and protected by RA 10173 Data
Privacy Act of 2012.
5 of 17
DOLE-BQF-WAIR
Health Hazard (Choose all that apply): Physical Chemical Biological Ergonomic None
Describe selected Health Hazard/s:
Printed Name of Injured Worker or Representative Sign above your name if you agree to the events narrated
Immediate Action done for the injured worker/s:
Corrective Measures planned and expected date of implementation to prevent recurrence of accident
(You may use another sheet if more space is needed, attach pictures if available):
6 of 17
DOLE-BQF-WAIR
Section III. Details of injured worker (skip section if more than 1 injured, use WAIR-B instead) o WAIR B used
Name of injured worker: Age: Sex:
Worker Address: Employment Status:
Average Weekly Wage: Length of service in Establishment:
Current work: Work hours/day: Work day/week:
Amount of time spent at current work: Years: Months: Days:
Body Part/s affected (indicate if left or right):
Extent of Disability: Permanent Total Permanent Partial Temporary Total
Hospitalization cost: Lost work days due to injury:
Return to work date: Nature of Injury:
Section IV. Cost of Accident
Approximate Cost to Operations (include cost of halting of production and cost to resume activities):
Less than Php 5,000 30,001 to 100,000 500,001 to 1,000,000
5,001 to 30,000 100,001 to 500,000 More than 1,000,000
Was there any damage to properties, materials or machinery? Yes No
Approximate Total Cost of Accident (Include expenses from Hospitalization, Cost to Operations,
Machinery repair and replacement, Compensation, Penalties, and Burial):
Less than Php 5,000 30,001 to 100,000 500,001 to 1,000,000
5,001 to 30,000 100,001 to 500,000 More than 1,000,000
We hereby certify that the information above is accurate to the best of our knowledge. We understand that the
OSH Standards states that these report shall not be admissible as evidence in any action or judicial proceedings
in respect to such injury, fitness or death on account of which report is made and shall not be made public or
subject to public inspection except for prosecution for violations under this Rule.
7 of 17
DOLE-BQF-WAIR
WAIR-A
event
None
8 of 17
DOLE-BQF-WAIR
AIR B used
9 of 17
DOLE-BQF-WAIR
We hereby certify that the information above is accurate to the best of our knowledge. We understand that this document is covered by the Data Privacy of 2012 and
that the Data Protection Officer or Data Privacy Manual was consulted on how to record, store and dispose this form.
10
DOLE-BQF-WAIR
We hereby certify that the information above is accurate to the best of our knowledge. We understand that this document is covered by the Data Privacy of
2012 and that the Data Protection Officer or Data Privacy Manual was consulted on how to record, store and dispose this form.
11
ILO Occupational Safety and Health Act, Dangerous Occurences, 2016
Category Description
D1 Lifting Machinery The Collapse of, the overturning of, or the failure of any load-bearing part of any (a) hoist; (b) crane or derrick; © mobile powered access
platform; (d) access cradle or window-cleaning cradle; (e) excavator; (f) pile-driving frame or rig having an overall height, when
operating, of more than 7 meters; or (g) fork lift truck.
D2 Pressure systems The failure of any closed vessel (including a boiler or boiler tube) or of any associated pipework, in which the internal pressure was
above or below atmospheric pressure, where the failure has the potential to cause death of any person.
D3 Freight Containers The failure of any freight container in any of its load bearing while it is being raised, lowered or suspended.
D4 Overhead electric Any unintentional incident in which plant or equipment either (a) comes into contact with an uninsulated overhead electric line in which
lines the voltage exceeds 200 volts; or (b) causes an electrical discharge from such an electric line by coming into close proximity to it.
D5 Electrical short circuit Electrical short circuit or overloaded attended by fire or explosion which results in the stoppage of the plant involved for more than 24
hours or which has the potential to cause the death of any person.
D6 Explosives Any incidents involving explosives including (a) the unintentional explosion or ignition of explosives other than (i) the one caused by the
unintentional discharge of a weapon where, apart from the unintentional discharge, the weapon and explosives functioned as they were
desgined to do; or (ii) where a fail-safe device or safe system of wok functioned so as to prevent an person from being injured in
consequence of the explosion or ignition; (b) a misfire (other than one at a mine or quarry or inside a well or one involving a weapon)
except where a fail safe device or safe system of work functioned so as to prevent any person from being endangered in consequence
of the misfire; (c) the failure of the shots in any demolition operation to cause the intended extent of collapse or direction of fall of a
building or structure; (d) the projection of material (other than at a quarry) beyond the boundary of the site on which the explosives are
being used or beyond the danger zone in circumstances such that any person was or might have been injured thereby; (e) any injury to
a person (other than at a mine or quarry or one otherwise reportable under these Rules) involving first-aid or medical treatment resulting
from the explosion or discharge of any explosives or detonator.
D7 Biological agents Any accident or incident which resulted or could have resulted in the release or escape of a biological agent likely to cause severe
human infection or illness.
D8 Malfunctions of Any incident in which(a) the malfunction of a radiation generator or its ancillary equipment used in fixed or mobile industrial radiography,
radiation generators the irradiation of food or the processing of products by irradiation, causes it to fail to deenergize at the end of the intended exposure
period; or (b) the malfunction of equipment used in fixed or mobile industrial radiography or gamma irradiation causes a radioactive
source to fail to return to its safe position by the normal means at the end of the intended exposure period.
D9 Breathing apparatus Any incident in which breathing apparatus malfunctions(a) while in use, or (b) during testing immediately prior to use in such a way that
had the malfunction occurred while the apparatus was in use it would have posed a danger to the health or safety of the user.
D10 Diving operations Any of the following incidents in relation to a diving operation(a) the failure or the endangering of (i) any lifting equipment associated with
the diving operation, or (ii) life support equipment, including control panels, hoses and breathing apparatus, which puts a diver at risk;
(b) any damage to, or endangering of, the dive platform, or any failure of the dive platform to remain on station, which puts a diver at
risk; (c) the trapping of a diver; (d) any explosion in the vicinity of a diver; or (e) any uncontrolled ascent or any omitted decompression
which puts a diver at risk.
D13 pipelines or pipeline The following incidents in respect of a pipeline or pipeline works(a) the uncontrolled or accidental escape of anything from, or inrush of
works anything into, a pipeline which has the potential to cause the death of, major injury or damage to the health of any person or which
results in the pipeline being shut down for more than 24 hours; (b) the unintentional ignition of anything in a pipeline or of anything
which, immediately before it was ignited, was in a pipeline; (c) any damage to any part of a pipeline which has the potential to cause the
death of, major injury or damage to the health of any person or which results in the pipeline being shut down for more than 24 hours; (d)
any substantial and unintentional change in the position of a pipeline requiring immediate attention to
safeguard the integrity or safety of a pipeline; (e) any unintentional change in the subsoil or seabed in the vicinity of a pipeline which has
the potential to affect the integrity or safety of a pipeline; (f) any failure of any pipeline isolation device, equipment or system which has
the potential to cause the death of, major injury or damage to the health of any person or which results in the pipeline being shut down
for more than 24 hours; or
(g) any failure of equipment involved with pipeline works which has the potential to cause the death of, major
injury or damage to the health of any person.
D14 Collapse of building Any unintended collapse or partial collapse of(a) any building or structure (whether above or below ground) under construction,
or structure reconstruction, alteration or demolition which involves a fall of more than 5 tons of material; (b) any floor or wall of any building (whether
above or below ground) used as a place of work; or (c) any false-work.
D15 explosion or fire An explosion or fire occurring in any plant or premises which results in the stoppage of that plant or as the case may be the suspension
of normal work.
D16 escape of flammable (1) The sudden, uncontrolled release (a) inside a building of(i) 100 kilograms or more of a flammable liquid, (ii) 10 kilograms or more of a
substances flammable liquid at a temperature above its normal boiling point, or (iii) 10 kilograms or more of a flammable gas; or (b) in the open air,
of 500 kilograms or more of any of the substances referred to in sub-paragraph (a).
D17 escape of substances The accidental release or escape of any substance in a quantity sufficient to cause the death, major injury or any other damage to the
health of any person.
D18 Except for Dangerous Occurences in relation to mines, quarries and Offshore workplaces are not included