DOLE/ BWC/ IP-6 Form

Republic of the Philippines

Department of Labor and Employment
BUREAU OF WORKING CONDITIONS
Region IV-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: Republic Cement & Building Materials Inc. (RCBMI)/ Tonijon Construction
2 Address: Barrio Mapulo, Taysan, Batangas
EMPLOYER
3 Name of Employer: Tonijon Construction- Alfredo Mercado
4 No. of Employees: Male: 69 Female: 3 Total: 72

5 Name: Ramel Cueto Age: 43 Sex: Male Civil Status: Married

INJURED OR 6 Address: PiÑa, Taysan, Batangas
ILL PERSON 7 Average Weekly Wage: PHP 2, 160 No. of Dependents: 3
8 Length of Service Prior to Accident / Illness: 6 years and 5 months

OCCUPA - 9 Occupation: Safety Officer Experience at Occupation: 1 year and 3 months

TIONAL
10 Work Shift: Day Shift 1st ___ 2nd____ 3rd_ Hours of Work / Day: 8 hours Days / Week: 6 days
HISTORY

11 Date of Accident / Illness: September 6, 2016 Time: 1:50 pm

12 Accident Involved: 1 employee Personal Injury: 1 Fatal Property Damage: none
13 Description of Accident:
Contractor Employee Hit by Fallen Debris (Please see attached Incident Notification for further details)
ACCIDENT/
ILLNESS

14 Was injured doing regular part of job at the time of accident or illness, if not, why? No
Because the group of Mr. Ramel Cueto has finish their activity (cement pouring of piping cooling system)
at the area. They were taking their shelter at the Finish Mill Area.

15 Extent of Disability: not applicable Fatal: 1 Permanent Total: not applicable

Permanent Partial: n/a Temporary Total: n/a Medical Treatment: n/a
NATURE & 16 Nature of Injury or Illness: 8.0 cm Lacerated wound with open skull fracture on frontal lobe; Depressed
EXTENT OF and palpable skull fracture on ocipital lobe; 8.0 inches long gaping lacerated wound on left leg with
INJURY / open fracture
ILLNESS Parts of Body Affected: frontal and ocipital lobes of skull; left leg
17 Date Disability Begun: September 6, 2016 Date Returned to Work: N/A
18 Days Lost: N/A or Days Charged: 6000 days

19 The Agency Involved: Roofing gutter with debris

20 The Agency Part Involved: Cement debris
CAUSE OF 21 Accident type: Fatality
ACCIDENT /
22 Unsafe Mechanical or Physical Condition: Presence of debris on roofing gutter
ILLNESS
23 The Unsafe Act: N/A
24 Contributing Factor: Heavy rain; Power outage; Accumulated cement build up
 25 Preventive Measures (taken or recommended): 1. Identification and mapping of structures with cement
build-up; 2. Removal of build-up on identified structures; 3. Removal of unsafe gutters at the plant
4. Reinforce existing gutters that have no support
PREVENTIVE
MEASURES
26 Mechanical guards, personal protective equipment and other safeguards provided: Immediately
installed scaffolding shelter on critical areas
27 Were all safeguards in use? yes If not, why? Not applicable
 28 Compensation: PHP 360/ day
29 Medical and Hospitalization: Not Applicable
30 Burial: PhP 65,000
MANPOWER 31 Time Lost on Day of Injury: Days: 6000 days Hours: 0 Minutes: 0
32 Time Lost on Subsequent Days: Hours: 0 Minutes: 0
33 Time on light work or reduced output: Not Applicable Days: 0 Hours: 0

34 Damage to Machinery and Tools (Describe): Not Applicable

MACHINERY 35 Cost of Repair or replacement: Not Applicable
AND TOOLS
36 Lost production time: Not Applicable Cost: Not Applicable

37 Damage to Materials (Describe): Not Applicable

MATERIALS 38 Cost of Repair or replacement: PHP 187,800
39 Lost production time: 9 days Cost: Not Applicable

40 Damage to Equipment (Describe): Not applicable

EQUIPMENT 41 Cost of Repair or replacement: Not Applicable
42 Lost production time: Not Applicable Cost: Not Applicable

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

EDWARD IAN B. CIPRIANO/ RCBMI/ H&S Manager ALFREDO A. MERCADO

Signature over Printed Name of Employer
Investigating Officer and Position

Date

Note: To be accomplished in triplicate

DOLE/ BWC/ IP-6 Form

Republic of the Philippines

Department of Labor and Employment
BUREAU OF WORKING CONDITIONS
Region IV-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: Republic Cement & Building Materials Inc. (RCBMI)/ Tonijon Construction
2 Address: Barrio Mapulo, Taysan, Batangas
EMPLOYER
3 Name of Employer: Tonijon Construction- Alfredo Mercado
4 No. of Employees: Male: 69 Female: 3 Total: 72

5 Name: Renato An Age: 52 Sex: Male Civil Status: Married

INJURED OR 6 Address: Sto. Nino, Taysan, Batangas
ILL PERSON 7 Average Weekly Wage: PHP 2, 340 No. of Dependents: 1
8 Length of Service Prior to Accident / Illness: 1 year and 2 months

OCCUPA - 9 Occupation: Welder Experience at Occupation: 27 years

TIONAL
10 Work Shift: Day Shift 1st ___ 2nd____ 3rd_ Hours of Work / Day: 8 hours Days / Week: 6 days
HISTORY

11 Date of Accident / Illness: September 6, 2016 Time: 1:50 pm

12 Accident Involved: 1 employee Personal Injury: 1 LTI Property Damage: none
13 Description of Accident:
Contractor Employee Hit by Fallen Debris (Please see attached Incident Notification for further details)
ACCIDENT/
ILLNESS

14 Was injured doing regular part of job at the time of accident or illness, if not, why? No
Because the group of Mr. Renato An has finish their activity (painting of piping cooling system)
at the area. They were taking their shelter at the Finish Mill Area.

15 Extent of Disability: not applicable Fatal: n/a Permanent Total: not applicable
Permanent Partial: n/a Temporary Total: 1 Medical Treatment: n/a
NATURE & 16 Nature of Injury or Illness: Closed Fracture Posterior 1st to 3rd left ribs; Blunt trauma posterior
EXTENT OF chest wall; pulmonary contusion; compression T6, T7 and T9 vertebral bodies
INJURY /
ILLNESS
17 Date Disability Begun: September 6, 2016 Date Returned to Work: TBD
18 Days Lost: TBD or Days Charged: N/A

19 The Agency Involved: Roofing gutter with debris

20 The Agency Part Involved: Cement debris
CAUSE OF 21 Accident type: Fatality
ACCIDENT /
22 Unsafe Mechanical or Physical Condition: Presence of debris on roofing gutter
ILLNESS
23 The Unsafe Act: N/A
24 Contributing Factor: Heavy rain; Power outage; Accumulated cement build up
 25 Preventive Measures (taken or recommended): 1. Identification and mapping of structures with cement
build-up; 2. Removal of build-up on identified structures; 3. Removal of unsafe gutters at the plant
4. Reinforce existing gutters that have no support
PREVENTIVE
MEASURES
26 Mechanical guards, personal protective equipment and other safeguards provided: Immediately
installed scaffolding shelter on critical areas
27 Were all safeguards in use? yes If not, why? Not applicable
 28 Compensation: PHP 390/ day
29 Medical and Hospitalization: PHP 143,082.95
30 Burial: Not Applicable
MANPOWER 31 Time Lost on Day of Injury: Days: TBD Hours: 0 Minutes: 0
32 Time Lost on Subsequent Days: Hours: TBD Minutes: 0
33 Time on light work or reduced output: TBD Days: 0 Hours: 0

34 Damage to Machinery and Tools (Describe): Not Applicable

MACHINERY 35 Cost of Repair or replacement: Not Applicable
AND TOOLS
36 Lost production time: Not Applicable Cost: Not Applicable

37 Damage to Materials (Describe): Not Applicable

MATERIALS 38 Cost of Repair or replacement: PHP 187,800
39 Lost production time: 9 days Cost: Not Applicable

40 Damage to Equipment (Describe): Not applicable

EQUIPMENT 41 Cost of Repair or replacement: Not Applicable
42 Lost production time: Not Applicable Cost: Not Applicable

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

EDWARD IAN B. CIPRIANO/ RCBMI/ H&S Manager ALFREDO A. MERCADO

Signature over Printed Name of Employer
Investigating Officer and Position

Date

Note: To be accomplished in triplicate