Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

Bureau of Working Conditions
Intramuros, Manila

LABOR ADVISORY NO.

Series of 2022

EMPLOYER’S WORK ACCIDENT ILLNESS REPORT (WAIR)

Pursuant to Section 6.II.A. of the Guidelines on the Nationwide Implementation

of Alert Level System for COVID-19 Response issued by the IATF 27 February 2022 1,
the submission of WAIR COVID FORM online shall no longer be mandatory.
Establishments however, shall still submit the Employer’s Work Accident/Illness Report
(WAIR) to the DOLE every 30'h of the month, with or without any accidents or
reportable work-related illnesses, including COVID cases, through the DOLE
Establishment Report System (https://reports.dole.qov.ph) in compliance to the
provisions of Rule 1050 of the Occupational Safety and Health Standards of the
Philippines. The WAIR Form may also be used as a supporting document for filing of
claims.

For compliance.

SI
Secretar
Dept. y
of Labor & £mployment
OF C 8 Of 04 B 4CIT 8/

1 6 March IIIIIIIIIIIIIIIIjtjjt|lIIlIlIIIIIIIIIIIIIIII
2022

' https.//www.officiaIgazette.gov.ph/downloads/2022/02feb/20220227-lATF-GUIDELINES-RRD.pdf
DOLE/BWC/OHSD/IP-6 If illness, fill in only gray blank!
If injury, completely fill in all blanks as appropriate

Republic of the Philippines

Department of Labor and Employment
BUREAU OF WORKING CONDITIONS
Manila
WAIR A
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 20th day of the month following the date of occurrence.)

1. Establishment:
2. Address:
EMPLOYER Nature of Business:
3. Name of Employer:
Nationality:
4. Number of Employees: Male Female Total
INJURED 5. Name:
PERSON Age: Sex:
(Use WAIR-B 6. Address:
for multiple
injured 7. Average Weekly Wage: P No. of Dependents:
Workers) 8. Length of service prior to accident or illness:
OCCUPATIONAL
HISTORY 9. Occupation: Experience at Occupation:
10. Time of Shift: (Ex 8am-5pm) Hours of work/day: Day/Week:
ILLNESS
11. Reportable Illness:
RECORD
Preferred
12. No. of Affected Worker's by Sex: Male Female not to say

13. No. of Affected Worker's by Age: >65 60-64 31-59

Preferred
25-30 18-24 15-17 < 15 not to say

14. Affected Worker's Work Location: Physically Reporting to Work

In Alternative Work Arrangement Hybrid/Combination
15. Control Instituted:
Engineering: Cost
Cost
Administrative: Cost
PPE:
16. Date of accident: Time:
17. The accident involved:
ACCIDENT Personal Injury: Property Damage:
18. Description of accident/illness (Give full details on how accident/illness occurred):

19. Was injured doing regular part of job at the time of accident or illness:
If not, why?
NATURE & 15. Extent of Disability (Number of Worker): Medical Treatment: Fa tal:
EXTENT OF Pemanent Partial: Temporary Total: Permanent Total:
INJURY/IES 16: Nature of injury: (see ILO Reference tab) Parts of Body Affected:
17. Date Disability Begun: Date Returned to Work:
DOLE/BWC/OHSD/IP-6 If illness, fill in only gray blanks
If injury, completely fill in aI| blanks as appropriate

18. Days Lost: or Days Charged:

19.
CAUSE OF 20.
ACCIDENT 21.
22.
23.
24.
25. Preventive Measures (taken or recommended):
26. Mechanical guards, personal protective equipment and other safeguards
PREVENTIVE
MEASURES 27. Were all safeguards in use? If not, why?

28. Compensation:
29. Medical and Hospitalization:
30. Burial:
31. Time Lost on Day of Injury:
MANPOWER Hrs. Mins.
32. Time Lost on Subsequent Days: Hrs. Mins.

(treatment or other reasons)

33. Time on light work or reduced output: Day:
Percent Output:
34. Damage to Machinery and Tools (Describe):
MACHINERY
AND 35. Cost of repair or replacement: P
TOOLS 36. Lost Production Time: COSt:

37. Damage to Materials (Describe):

MATERIALS
38. Cost of repair or replacement: P
39. Lost Production Time: COSt:

40. Damage to Equipment (Describe):

EQUIPMENT
41. Cost of repair or replacement: P
42. Lost Production Time: COSt:

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

Date

Investigating Officer & Position Employer

 DOLE-BQF-WAIR

Republic of the Philippines

Department of Lahor and Emplcyment
Regional Office
,.,:.. /.‹.
. ... ‹p.‹.
Work Accident I Injury Repoit Patients' Data
Page
For multiple worker involvement. Insert additional rows or pages as necessary.
To be attached to WAIR-A. WAIR-B
Length of Lenqth of Stay Work 'Nork"
Date of Acciclent: Average Weekly Service in What is
at Current hours Days
Time of Accident: Employment wage Establishment
the current
Work per per
wr›rk
Name of Injured Worker Age Sex Occupation Status Philippine Pe.so In years assicned: Years MODthS Day Week

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.

OH Personnel / Safety Officer

Signature beside printed name Employer / Representative
Signature beside printed name
1