Republic of the Philippines DEPARTMENT OF LABOR
AND EMPLOYMENT Intramuros, Manila
ESTABLISHMENT REPORT ON COVID-19
_______________________________________
(Region-PO/FO-Year-Month-Count)
(ex. NCR-MFO-2020-02-001)
Instructions:
1. Accomplish this form in two copies when filing a notice of: a) Flexible Work Arrangement or b) Temporary Closure. The
report is considered as duly filed when the complete list of workers affected is made part of the submission.
2. This form should be submitted to the DOLE Regional/Provincial/Field Office at least thirty (30) calendar days prior to
the effectivity of temporary closure or at least one (1) week prior to the implementation of FWA.
3. Page 1 should contain general information about the establishment and the number of workers affected.
4. Page 2 should enumerate the names of workers affected, their addresses and contact numbers, position title and
salary.
5. Total number of workers listed should equal the total number of workers affected as reported in this page.
A. Establishment Data
Name of Establishment:
Floor/Bldg/No/Street/Subdivision
: Barangay/City/Municipality:
Kind of Business/Economic
Activity/Principal Product:
Number of Workers: Male: Managerial Employees:
Female: Supervisory:
Total: Rank and File:
Total:
Date of Filing: (mm/dd/yyyy)
B. Summary of Affected Workers due
to B.1 Flexible Work Arrangement
Type of Flexible Work Arrangement
No. of Workers Effectivity Date
to be Implemented
Covered/Affected (mm/dd/yyyy)
(Use code below, select only one)
Codes for Flexible Work Arrangement Scheme:
RW - Reduction of Workdays FL - Forced Leave
RE - Rotation of Employees OTH - Others (Specify) ____________
B.2 Temporary Closure
No. of Workers Effectivity Date Main Reason of Temporary Closure
Covered/Affected (mm/dd/yyyy) (Use code below, select only one)
Codes for Main Reason for Temporary Closure:
LM - Lack of Market/Slump in Demand I - Infection (COVID-19)
LRM - Lack of Raw Materials OTH - Others (Specify) ____________
CERTIFICATION
This is to certify as to the accuracy of the data provided in this report.
Name and Signature of Owner/Company Representative:
Designation: Fax No.:
Contact No.: Email Address:
FOR DOLE (Regional/Provincial/Field Office) USE ONLY:
Updates/Remarks:
a) Provision of assistance (please specify) _______________________________________________________
b) Estimated period of resumption of normal business operations: ____________________________________
c) Others (please specify) ____________________________________________________________________
Name and Signature of DOLE Authorized Representative: Date Updated:
Republic of the Philippines DEPARTMENT OF LABOR AND
EMPLOYMENT Intramuros, Manila
LIST OF AFFECTED WORKERS DUE TO COVID-19
Instructions: If necessary, use additional sheets following the same format.
Profile of Affected Workers
Employment
No. Name of Worker Age Sex Home Address Contact Designation Status Salary1
(Last Name, First Name, M.I.) Number (regular,
contractual, etc.)
1 Aballe,Alian Jay R. 25 M Makilala,North Cot. 09091927394 Driver Regular 350/day
2 Balagtas,Kazel Mae S. 25 F Makilala,North Cot. 09469751604 Encoder Regular 350/day
3 Brua,Lester James H. 30 M Makilala,North Cot. 09383690360 Purchaser Regular 325/day
4 Calinga,Diego L. 53 M Makilala,North Cot. 09187185762 Supervisor Regular 500/day
5 Culanggo,Jan Rey H. 25 M Pres.Roxas,North Cot. 09306281286 Encoder Regular 325/day
6 Gelicame,John Mar L. 26 M Kidapawan City 09215224422 Programmer Regular` 550/day
7 Kalaw, Jesriel A. 34 M Makilala,North Cot. 09124427785 Driver Regular 450/day
8 Malayan,Juluis B. 36 M Makilala,North Cot. 09075229495 Purchaser Regular 400/day
9 Montojo,Mark Ian Sr S. 31 M Makilala,North Cot. 09307035514 Driver Regular 325/day
10 Bangi,James Carlo A. 30 M Makilala,North Cot. 09993098464 Liaison Regular 375/day
11 Olita,Edwin R. 27 M M’lang,North Cot. 091220376094 Liaison Regular 400/day
12 Layos,Sanny D. 37 M Antipas,North Cot. 09485227072 Driver Regular 350/day
13 Hatamosa,Michelle T. 23 F Pres.Roxas,North Cot. 09463797858 Eng’g Aide Contractual 200/day
14 Manguilimotan,Precious Amor N. 23 F Magpet,North Cot. 09301693985 Eng’g Aide Contractual 200/day
15 Manticayan,Mae Ann S. 22 F Magpet,North Cot. 09098397815 Eng’g Aide Contractual 200/day
16 Saac,Lester James C. 22 M Kidapawan City 09206460821 Eng’g Aide Contractual 200/day
17 Guisadio,Ryan Debb G. 21 M Kidapawan City 09125909755 Eng’g Aide Contractual 200/day
18 Requinton,Jeo G. 21 M Kidapawan City 09099113121 Eng’g Aide Contractual 200/day
19 Umbay,Erick C. 22 M Kidapawan City 09516566584 Eng’g Aide Contractual 200/day
20 Berangel,Jhon Philip A. 21 M Makilala,North Cot. 09389631677 Eng’g Aide Contractual 200/day
21 Tan,Angel Claire D. 21 F Kidapawan City 09103095368 Eng’g Aide Contractual 250/day
22 Dela Cruz,Emilio Jr D. 52 M Kidapawan City 091224322698 Foreman Regular 600/day
23 Albaraan, Nelson T. 30 M Kidapawan City 09513888549 Welder Regular 450/day
24 Balberan,Cornelio C. 49 M Kidapawan City 09105289637 Carpenter Regular 450/day
25 Gapati,Jose P. 42 M Kidapawan City 09105289637 Mason Regular 450/day
26 Cayno,Juvani 39 M Kidapawan City 09101132578 Welder Regular 450/day
27 Gibinga,Nolasco B. 58 M Kidapawan City 09104502717 Mason Regular 450/day
28 Tabunao,Sanbert L. 25 M Kidapawan City 09105257976 Mason Regular 450/day
29 Valenzuela,Redgen A. 47 M Matalam.North Cot. 09501279221 Mason Regular 450/day
30 Valenzuela,Arvie A. 23 M Matalam.North Cot. 09501279221 Mason Regular 450/day
1
Indicate whether per hour, per day or per month
