DOLE/BWC/OHSD/1P-6

Republic of the Philippines

DEPARTMENT PF LABOR AND EMPLOYMENT
BUREAU OF WORKING CONDITIONS
Baguio City

EMPLOYER’S WORK ACCIDENT/ILLNESS REPORT

(This report shall be submitted by the employer for every accident or illness to the Regional Office having jurisdiction on or before the 20 th day of
the month following the date of occurrence.)

1. Establishment:MATAGOAN KJ BUILDERS AND ENGINEERING SERVICES

EMPLOYER 2. Address: BULANAO, TABUK CITY Nature of Business: CONSTRUCTION
3. Name of Employer: JENRAY P. NALOG Nationality: FILIPINO
4. No. of Employees: 7 Male: 2 Female: 9Total: 9

INJURED 5. Name: NO ACCIDENT REPORTED DURING THE PROJECT

Age: _____ Sex _____ Civil Status:_______
OR ILL 6. Address: _______________________________________________________
PERSON 7. Average Weekly Wage: P___________ No. of Dependents: ______________
8. Length of service prior to accident or illness:

OCCUPATIONAL 9. Occupation: _____________ Experience at Occupation: _________________

HISTORT 10.Work Shift:___1st____2nd____3rd___Hours of work/day:_____Day/Week___

11. Date of accident/Illness: __N/A_____________________Time: ____ N/A _________

12. The accident involved: __ N/A ________Personal Injury _______ N/A _____________
ACCIDENT Property Damage _____ N/A ___________
OR 13. Description of accident/illness (Give full details on how accident/illness
ILLNESS occured):_____ N/A ____________________________________________________
________________________________________________________________
14. Was injured doing regular part of job at the time of accident or illness:
If not, why? ____ N/A _______________________________________________

15. Extent of Disability: _ N/A ___ Fatal _ N/A ___ Permanent Total__________________
NATURE & Permanent Partial __ N/A ___Temporary Total __ N/A __ Medical Treatment ___
EXTENT OF 16. Nature of Injury or Illness: ____ N/A __ Parts of Body Affected: ___ N/A ___________
INJURY OR 17. Date Disability Begun: ______ Date Returned to Work _____ N/A ____________
ILLNESS 18. Days Lost: ______ N/A __________ or Days Charged: _________ _____________

19. The Agency Involved: ___ N/A ________________________________________

CAUSE OF 20. The Agency Part Involved: __ N/A ______________________________________
ACCIDENT 21. Accident Type: ___ N/A ______________________________________________
OR ILLNESS 22. Unsafe Mechanical or Physical Condition: _ N/A __________________________
23. The Unsafe Act: ___ N/A _____________________________________________
24. Contributing Factor: __ N/A ___________________________________________

25. Preventive Measures (taken or recommended): ___ N/A _____________________

PREVENTIVE 26. Mechanical guards, personal protective equipment and other safeguards
MEASURES provided: ___ N/A ______________________________________________________
27. Were all safeguards in use? __ N/A ____ If not, why? ____ N/A ___________________
______________________________________________________________

28. Compensation: _____ N/A _______________ P ___________________________

29. Medical and Hospitalization: ___________ N/A ___________________________
30. Burial:____ N/A ____________________________________________________
MANPOWER 31. Time Lost on Day of Injury:____ N/A ___________________________________
32. Time Lost on Subsequent Days:__ N/A _____ Hrs. _______ Mins. ____________
(treatment or other reasons)
33. Time on light work or reduced output: _ N/A _________ Day ________________
Percent Output: __________________

34. Damage to Machinery and Tools (Describe): ___ N/A ______________________

MACHINERY 35. Cost of repair or replacement: __ N/A ___________________________________
AND TOOLS P______________________________
36. Lost production Time: _____ N/A ______________ Cost:______ N/A _____________

37. Damage to Materials (Describe):____ N/A _______________________________

MATERIALS 38. Cost of repair or replacement: ______ N/A _______________________________
P _____________________________________
39. Lost Production Time: _ N/A ____________________ Cost: __ N/A _______________

I HEREBY CERTIFY on my honor to the accuracy of the foregoing information.

April 19, 2021 DAISY JANE F. MACALING JENRAY P. NALOG

Date Safety Officer Managing Officer