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 Office having
jurisdiction on or before the 20th day of the month following the date of the accident) For the month of __________.
I HEREBY CERTIFY on my honor to the accuracy of the foregoing information.
EMPLOYER
1. ESTABLISHMENT: ______________________________________________________________
2. ADDRESS: _____________________________________________________________________
3. NAME OF EMPLOYER___________________ NATURE OF BUSINESS: _________________
4. NO. OF EMPLOYEES: ____ MALE: ____ FEMALE: ____ TOTAL: _____________________
INJURED
OR
ILL PERSON
5. NAME: _________________________ AGE: ____ SEX: ____ CIVIL STATUS: ____________
6. ADDRESS: _____________________________________________________________________
7. AVE. WEEKLY WAGE: __________________________________________________________
8. LENGTH OF SERVICE PRIOR TO ACCIDENT OR ILLNESS: ___________________________
9. OCCUPATION: ________________ EXPERIENCE AT OCCUPATION: ___________________
10.WORK SHIFT:_____ 1ST: _____ 2ND: _____3RD HOURS OF WORK/DAY:_____ WEEK: _____
ACCIDENT
OR
ILLNESS
11.DATE OF ACCIDENT/ILLNESS: ________________________________ TIME: ____________
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/ILLNESS?
IF NOT? WHY? _________________________________________________________________
NATURE
AND
EXTENT OF
INJURY OR
ILLNESS
15.EXTENT OF DISABILITY: ____________ FATAL: ________ PERMANENT TOTAL: ______
PERMANENT PARTIAL: _____________ TEMPORARY TOTAL: _______________________
MEDICAL TREATMENT: _________________________________________________________
16.NATURE OF INJURY/ILLNESS: _________ PART OF THE BODY AFFECTED: ___________
17.DATE OF DIABILITY BEGAN: ___________ DATE RETURNED TO WORK: _____________
18.DAYS LOST: ______________________ OR DAYS CHARGED: ________________________
CAUSE OF
ACCIDENT
OR ILLNESS
19.THE AGENCY INVOLVED: _______________________________________________________
20.THE AGENCY PART INVOLVED: _________________________________________________
21.ACCIDENT TYPE: _______________________________________________________________
22.UNSAFE MECHANICAL OR PHYSICAL CONDITION: ________________________________
23.UNSAFE ACT: __________________________________________________________________
24.CONTRIBUTION FACTOR: _______________________________________________________
PREVENTIVE
MEASURE
25.PREVENTIVE MEASURE (TAKEN OR RECOMMENDED): ____________________________
26.MECHANICAL PERSONAL PROTECTIVEEQUIPMENT AND OTHER SAFEGUARD: _____
_______________________________________________________________________________
27.WERE ALL SAFEGUARD IN USE? _________ IF NOT? WHY? _________________________
MANPOWERED
28.COMPENSATION: ______________________________________ P ______________________
29.&30. MEDICAL AND HOSPITALIZATION….. _______________________________________
BURIAL…. _____________________________________________________________________
31.TIME LOST ON DAY OF INJURY…HOURS: _________________ MINUTES: _____________
32.TIME LOST ON SUBSEQUENT DAYS, HOURS: ______________ MINUTES: _____________
(LOST TREATMENT OR OTHER REASON)
33.TIME OR LIGHTWORK OR REDUCED OUTPUT DAY: ______ PERCENT OUTPUT: ______
MACHINERY
AND TOOLS
34.DAMAGE OF MACHINERY AND TOOLS (DESCRIBED): _____________________________
35.COST OF REPAIR OR REPLACEMENT …………………. P_____________________________
36.LOST OF PRODUCTION TIME: _______________ COST: P_____________________________
MATERIALS 37.DAMAGE TO MATERIALS (DESCRIBED): __________________________________________
38.COST OF REPAIR OR REPLACEMENT ……………….… P_____________________________
39.LOST OF PRODUCTION TIME: _______________ COST: P_____________________________
EQUIPMENT 40.DAMAGE TO EQUIPMENT (DESCRIBED): _________________________________________
41.COST OF REPAIR OR REPLACEMENT ……………….… P_____________________________
42.LOST PRODUCTION ON TIME: _______________COST: P_____________________________
____________________________
DATE
________________________________ ____________________________
Investigating Officer & Position VP-FINANCE
