lf illfless, fill ln only gray blanks

DOLE/BWC/OHSD/lp-6
lf injury, completely fill in all blanksas appropriate

Republic of the Phlllppines

Department of Labor and Employment
BUREAU OF WORKING CONDITIONS

ap~ dfe frobl Manila

gr+-jfh,. WAIR-A

EMPLOYER'S WORK ACCIDENT/lLLNESS 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. Numberof Employees: Male Fema le Total

lNJURED 5. Name:
PERSON Age: Sex: Civil Status:
(usewAIR-B 6. Address:
for muitiple
7. Average Weekly Wage: ? No. Of Dependents:
injured
Workers) 8. Length Of service prior to accident or illness:
OCCUPATIONAL
HISTORV 9. Occupation: Experience at Occupation:
10. Time of shift: (Ex. 8 AM-5 PM) Hours of work/day: Day/Week:

lLLNESS 11. Reportable Illness:

t Preferred
RECORD
12, No. of Affected worker's by sex: Male Female not to say

13. No. of Affected worker`5 by Age. i 65 31'59

Preferred
25-30 18-24 15-17 not to S{|Y

14. Affected woi.ker's work Location: Physically Reportlng to work

ln Altemative work Arrangement Hybrid/Ccmbination
15. Control Instituted:
Engineering: 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:
lf not, why?

NATURE & 15. Extent of Disability (Number of worker): Medical Treatment: Fatal:
EXTENT OF Pemanent partial: Temporary Total: Permanent Total:
INJURY/lES 16: Nature of injury: (see ILO Reference I.ib) Parts Of Body Affected:
17. Date Disability Begun; Date Returned to Work:
 lf illness, fill in only gray blaiiks
DOLE/BWC/OHSD/lp-6
lf ir\jury, Completely fill {n all b!anl<sas appropriate

18. Days Lost: or Days Charged:

i__ _i_ -----
',i.f,.i\`Jit,[:;ii!`:a,ticiLji3!ti{:!TL,(;I:timiL`ai.i
19. The Agency Involved:
I:-|chillv3).
CAUSE OF 20. The Agency part Involved: (`jij¢cifi?: i:iai't ci{` ,.`f`i`.ii:.imont.j`i.i

ACCIDENT 21. AccidentType: {i..f,-:I ill:i r{!:Ii:r3r`:^nr;rtfih)

22. Unsafe Mechanial or Physical Condition:
23, The un5afe Act:
24. Contrlbuting Factor:

25® Preventlve Measures (taken or rec:ommended}:

26. Mechanjcal guards, personal protectiv\e equipment and other safeguards
PREVENTIVE

MEASURES 27, Were all 5afeguard§ in use? lf not, why?

28. Compensation:
29. Medical and Hospitalization:
30. Burial:
31. Time lost on Day of Injury;
MANPOWER
32. Tlme Lost on Subsequent Days:
(treatment or other reasons)
33. Time on light work or reduced output:
Percent Output:

34. Damage to Machinery and Tools (Describe):

MACHINERY
AND 35. Cost of repair or replacement: P
TOOLS 36. Lost Production"me:

37. Damage to Materials (Describe):

MATERIALS

38. Cost of repair or replacement: F

39. Last production Time: Cost:

40. Damage to Equipment (Describe):

EQUIPMENT
41. Cost of repalr or replacement: P
42. Lost production Time: Cost:

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

Investigating Officer & Position Employer