Notification of Company’s Safety Milestone

Department of Labor and Employment

Bureau of Working Conditions Effectivity Date:
Approved by:
Occupational Health and Safety Division July 31, 2007 BRENDA L. VILLAFUERTE, CESO III

Subject: Notification on Companies’ Safety Milestone

Instruction: This Form can be accomplished and submitted by the company with any of the following safety milestone:
- has achieved zero lost time accidents for one whole calendar year (January to December)
- 1 million safework-hours without lost time accidents
- has completed a construction project without lost time accidents and involved an average of not less than 200 workers.
- At least one (1) million aggregate man-hours for several/consecutive/concurrent construction projects.
Company Profile
Complete Company Name Address

Contact Number:
Email Address:
Nature of Workplace (please check) Type of Industry (e.g. Manufacturing, construction etc.) :
____________________________
Hazardous Non hazardous Product Produced or
Highly hazardous Services offered (please specify ) __________________________________________

Safety Performance (Including Subcontractor/s if any)

Covered Period: From To: Ave. Number of workers
For the covered period
mm dd yyyy mm dd yyyy
Total Man-hours work without lost time accidents: Estimated economic savings in terms of pesos
(Ave no.of workers x no.of hours per day x no. of working days for the from having achieved zero lost time
covered period): accidents if available)
X X =

Sub-Contractors Profile (use additional sheet if necessary)

No. of
Name of Safety
workers Nature of Safe
Officer//Practitioner Covered
Name of Sub-contractors (involve Activity/ Man-hours
(indicate accreditation # & Period
in the Services (NLTA)
validity)
project)

Company’s OSH Systems/Programs/Projects/activities/Current Efforts on OSH:

Described briefly significant achievements and other highlights of its safety and health efforts on OSH (attach
another sheet if necessary

Name of Accredited OSH Practitioner/s

Accreditation Number and Validity
or Consultant/s

Please check
______ Certification of no pending case/violations on General Labor Standards issued by DOLE-RO ________
______ The company has submitted the ff. OSHS Reporting Requirements:
_____ Rule 1020: Registration Date approved/received by DOLE-RO ___________
_____ Report of Safety Organization (Safety and Health Organizational Structure which
specify the name of each member
_____ AMR for the covered period
_____ Annual Exposure Data Report (AEDR)
(Photo copy of the abovementioned forms submitted must be attached )
We hereby certify to the veracity of the abovementioned information.

Prepared by: ________________________

Safety Officer/Practitioner
Submitted by :
_____________________________________
(Employer)