Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

BUREAU OF WORKING CONDITIONS

Manila

Work Accident / Injury Report

Workers' Data Page

To be attached to WAIR-A
WAIR-B

Personal Information Employment Details Illness Nature / Extent of Injury

Length
of
Average Service Years of Part/s Date
Name Weekly Prior to Experie Work Work Reporta Date Date Extent Date
of No. of
Civil Addres Depend Occupa Employ Returne Days Day/s of Nature of the Disabili Returne Days Day/s
Age Sex ment Wage Acciden nce at Hours/ Days/W ble Illness Charge Disabili of Body Charge
Injured Status s tion t or Occupa Day d to Lost ty d to Lost
Worker ents Status eek Illness Begun Work d ty Injury Affecte Begun Work d
Illness tion d
Philippi In years
ne Peso
No data available in table