DOLE/BWC/OHSD/IP-6

Republic of the Philippines

Department of Labor and Employment
BUREAU OF WORKING CONDITIONS
Manila
EMPLOYER’S WORK ACCIDENT/ILLNESS REPORT
(This report shall be submitted by the employer for every accident or illness to the Regional
th
Office having jurisdiction on or before the 20 day of the month following the date of occurrence.)

EMPLOYER 1. Establishment: ____________________________________________________

2. Address: _________________________Nature of Business: ________________
3. Name of Employer: ______________________ Nationality:________________
4. No. of Employees: __________Male: ___________ Female: _______________

INJURES OF ILL 5. Name: ____________________ Age: _____Sex: ____ Civil Status: __________
PERSON 6. Address: ________________________________________________________
7. Average Weekly Wage: P_____________ No. of Dependents: ______________
8. Length of service prior to accident or illness: ____________________________
OCCUPATIONAL 9. Occupation: _________________ Experience at Occupation: _______________
HISTORY 10. Work Shift: ___ 1st __ 2nd __ 3rd __ Hours of work/day:___ Day/Week: _____

ACCIDENT OR 11. Date of accident/illness: _____________________ Time: __________________

ILLNESS 12. The accident involved: __________________ Personal Injury: ______________
Property Damage: ___________
13. Description of accident/illness (Give full details on how accident/illness
occurred): _______________________________________________________
________________________________________________________________
14. Was injured doing regular part of job at the time of accident or illness:
If not, why? ______________________________________________________

NATURE OF 15. Extent of Disability: ________ Fatal_____ Permanent Total _____________

EXTENT OF Permanent Partial ______Temporary Total________ Medical Treatment _____
INJURY OR 16. Nature of Injury or Illness: ________ Parts of Body Affected: _______________
ILLNESS 17. Date Disability Begun: ___________Date Returned to Work _________
18. Days Lost: ____________________ or Days Charged: ____________________

CAUSE OF 19. The Agency Involved: _______________________________________________

ACCIDENT OR 20. The Agency Part Involved: __________________________________________
ILLNESS 21. Accident Type: ___________________________________________________
22. Unsafe Mechanical or Physical Condition: ______________________________
23. The Unsafe Act: __________________________________________________
24. Contributing Factor: _______________________________________________

PREVENTIVE 25. Preventive Measures (taken or recommended): _________________________

MEASURES 26. Mechanical guards, personal protective equipment and other safeguards
provided: _______________________________________________________
27. Were all safeguards in use? _______ If not, why? ________________________

MANPOWER 28. Compensation:_________________P ____________________

29. Medical and Hospitalization: ________________________
30. Burial: _______________________
31. Time Lost on Day of Injury: _________________________________________
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: ___________________
MACHINERY AND 34. Damage to Machinery and Tools (Describe): ____________________________
TOOLS 35. Cost of repair or replacement: ______________________________________
P_____________________
36. Lost production Time: ___________________________ Cost ______________

MATERIALS 37. Damage to Materials (Describe): _____________________________________

38. Cost of repair or replacement: ______________________________________
P_____________________
39. Lost production Time: ___________________________ Cost ______________

EQUIPMENT 40. Damage to Equipment (Describe): ____________________________________

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