Instructions:

Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT
lntramuros, Manila
ESTABLISHMENT REPORT ON COVID-19
REGION 10, MISAMIS ORIENTAL
(Reglon-PO/FO-Year-Month-Count)

1. Accomplish this fonn in two copies when filing a notice of: a) Flexible Work Arrangement or b) Temporary Closure. The report is considered as duly filed when
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 workersJisted should equalthe total number of workers affected as repbrted in this page.
A. Establishment Data
Name of Establlshment•: (Please Indicate rvgfsterad nemo as tVllected in th& bus/non permit)
Floor/Bldg/No/Street/Subdlvls Ion•: Gingoog Grocers, Dona Graciana St
Barangay/CltylMunlclpallty*:
Kind of Buslneas/Economlc Activity/Principal Product:
Number of Workers•:
Barangay 20 Gingoog City
Who lesale and Retail Business
Male: 05 Managerial Employees:

Female: 11 Supervisory :
Total: 16               Rank and File:
Total:

    NONE    
     01        
      15          
      16            
Date of Fiiing•: (mmlddlyyyy)
   04108 12020                                                               
B. Summary of Affected Workers due to
B.1Flexible Work Arrangement•
No. of Workers Effectlvfty Date Type of Flexible Work Arrangement
Covered/Affected (mmlddlyyyy) to be Implemented
Use code below select onl one
16 03/ 31/2020 RW
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Corhs for Flexible Wo1*Aming«nent Scheme:
RW - Reduction of Workdays FL - Forced Leave
RE - Rotation of Employees
B.2 Temporary Closure•
OTH - Others (Specify) _
No. of Workers Effectlvlty Data Main R..son of Temporary Closure
Covered/Affected mmlddl Use code below select onl one
NONE
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Codes for Main Reason for Temponty Closure:
LM - Lad( of Market/Slump In Demand
LRM - Lack of Raw Materials
I- Infection (COVID-19)
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.:

OWNER/PROPRIETOR
Contact No.: Email Address:jnverdejo@outlook.com
0977-612-3076/ 088-328-040 1
FOR DOLE (Regional/Provinelal/Fleld Office) USE ONLY:
Updates/Remarks, If any:
RecelvedNerlfled 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)
Date:
--
Name and Signature of DOLE Representative:
D•te: __
ure. 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 com
(*) should be accomplished by the company representative for COVID· 19Adjustment Measures Program applications .