Occupational Safety and Health

(OSH) Program of
(Company Name)

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 Complete Company Profile/ Project Details

Company Name: ____________________________________________

Date Established: ____________________________________________

Complete Address: ____________________________________________

Phone and fax numbers ____________________________________________

Website URL/Email address ____________________________________________

Name of Company
____________________________________________
Owner/Manager/President

Total Number of Employees: _________ Male: _______ Female: _______

Description of the business ___________________________

Kindly check:
o Manufacturing: ____________________________________________

o Service: ____________________________________________

o Agri/fishing: ____________________________________________

o Wholesale/retail ____________________________________________

o Utilities ____________________________________________

o Banks and
____________________________________________
financial
institution
o Security Agency ____________________________________________

o Maintenance ____________________________________________

o Construction ____________________________________________

o Others ____________________________________________

Product descriptions: (ex.

____________________________________________
Garments, shoes, electronics)

Description of services:
____________________________________________

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 Basic Components of Company OSH Program and Policy
(DO 198-18, Chapter IV, Section 12)

1.0 Company Commitment to Comply with OSH Requirements

2.0 General Safety and Health Programs
- Safety and health Hazard Identification, Risk Assessment and Control
(HIRAC)
- Medical Surveillance for early detection and management of
occupational and work-related diseases
- First aid and emergency medical services
3.0 Promotion of Drug-Free Workplace, Mental Health Services in the Workplace,
Healthy Lifestyle
4.0 Prevention and Control of HIV-AIDS, Tuberculosis, Hepatitis B
5.0 Composition and Duties of Health and Safety Committee
6.0 OSH Personnel and Facilities
7.0 Safety and Health Promotion, Training and Education
- Orientation of all workers on OSH
- Conduct of Risk Assessment, Evaluation, and Control
- *Continuing training on OSH for OSH Personnel
- *Work Permit System
8.0 Toolbox/Safety Meetings, job safety analysis
9.0 Accident/Incident/illness Investigation, Recording and Reporting
10.0 Personal Protective Equipment (PPE)
11.0 Safety signages
12.0 *Dust control and management and regulation on activities such as building
of temporary structures and lifting and operation of electrical, mechanical,
communications system and other requirements
13.0 Welfare Facilities
14.0 Emergency and disaster preparedness and response plan to include the
organization and creation of disaster control groups, business continuity
plan, and updating the hazard, risk, and vulnerability assessment (as
required)
15.0 Solid waste management system
16.0 Compliance with Reportorial Government Requirement (refer to Item 9.0)
17.0 Control and Management of Hazards (refer to Item 2-HIRAC)
18.0 *Prohibited Acts and Penalties for Violations
19.0 *Cost of Implementing Company OSH program

*(Applicable for medium to high-risk establishments with 10 to 50 workers and low to

high-risk establishments with 51 workers and above)

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1.0. Company Commitment to Comply with OSH Policy

____________ (Name of the Company) ___________ do hereby commit to comply

with the requirements of RA 11058 and DOLE Department Order 198-18 (its
Implementing Rules and Regulations) and the applicable provisions of the
Occupational Safety and Health Standards (OSHS).

We acknowledge the company’s obligation and responsibilities to provide appropriate

funds for implementing this OSH program including orientation and training of its
employees on OSH, provision and dissemination of IEC materials on safety and
health, provision of Personal Protective Equipment (PPE) when necessary and other
OSH related requirements and activities, to ensure the protection for our workers and
employees against injuries, illnesses and death through safe and healthy working
conditions and environment.

We commit to conduct risk assessment as required to prevent workplace accidents

as well as comply with other provisions of this OSH program. That we are also fully
aware of the penalties and sanctions for OSH violations as provided for in RA 11058
and its Implementing Rules and Regulations.

[Signature] ______________________________

[Name] _________________________________
[President] / [Chief Executive Officer] / [Owner]
[Date] __________________________________

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 2.0. General Safety and Health Programs
2.1. Conduct of Risk Assessment

Kindly accomplish. Please use additional pages if needed. You may also attach your
Company’s Risk Assessment Matrix as substitute.
Risk Assessment Matrix
Priority: likelihood of
injury and illness to
Control
Task Hazard Identified Risk Description occur
Measures
(low, medium, high)

Example of Simple Risk Assessment

Task Hazard Risk Priority Control
May be unable to
Need for
Drivers work alone call for help if high
helper
needed
Drivers have to
Fatigue, short rest Policy on
occasionally render long medium
time between shifts work break
Delivering hours of work
product to Increased chance of Road safety
low
customers Drivers are often in very collision program
congested traffic Longer working
medium Work breaks
hours
Injury to back from Given proper
Drivers have to lift boxes
lifting, reaching, high orientation on
when delivering product
carrying, etc. lifting

2.2. Medical Surveillance

The company shall require all employees to undergo a baseline or initial
medical health examination prior to assigning to a potentially hazardous
activity. The examination will include but not limited to the following:

a. Routine: ( ) CBC ( ) Chest X-ray ( ) Urinalysis ( ) stool exam

b. Special: ( ) Blood Chemistry ( ) ECG ( ) others, please specify
c. Schedule of Annual medical examination: ( ) Q1 ( )Q2 ( )Q3
( )Q4
d. Is random drug testing conducted? Yes_____ when_______) No
______

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 2.3. First-Aid, Health Care Medicines and Equipment Facilities

 How many treatment rooms/first aid rooms are existing in your company?
______
 How many Clinics in the workplace? _______
 What hospital (s) are you affiliated with? _______

3.0. Promotion of Drug-Free Workplace, Mental Health Services in the

Workplace, Healthy Lifestyle
4.0. Prevention and Control of HIV-AIDS, Tuberculosis, Hepatitis B

This refers to: Drug-free Workplace in compliance to RA 9165, Human

Immunodeficiency Syndrome (HIV/AIDS) in compliance to (RA 8504) RA 11166,
Tuberculosis in compliance to EO 187-03, Hepatitis B in compliance to DOLE
Advisory No. 05 Series of 2010, Mental Health in compliance to RA 11036.

Kindly accomplish the policy template in Annex A. Individual policy statements may
be attached.

5.0 Composition and Duties of Safety and Health Committee

The SHC of the company is responsible to plan, develop and implement OSH
policies and programs, monitor, and evaluate OSH programs and investigate all
aspect of the work pertaining to the safety and health of all the workers. SHC shall be
composed of the following in compliance with the law:

(a) For establishments with less than ten workers and low risk
establishments with ten (10) to fifty (50) workers. – A SO1 shall establish an OSH
committee composed of the following:

Chairperson : __________________________________________________
Name of Company owner or manager

Secretary :
_________________________________________________
Safety officer of the workplace

__________________________________________________
Member : Name of at least one (1) worker, preferably a
union member, if organized

(b) For medium to high-risk establishments with ten (10) to fifty (50) workers
and low to high-risk establishments with fifty-one (51) workers and above. – The
OSH committee of the covered workplace shall be composed of the following:

Ex-officio : _______________________________________________
chairperson Name of Employer or his/her representative

Secretary : ________________________________________________
Name of Safety officer of the workplace

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 Ex-officio :
members ________________________________________________
Name of Certified first-aider/s
_________________________________________________
Name of OH nurse
_________________________________________________
Name of OH dentist, and OH physician, as applicable

__________________________________________________
Members : Name of Safety officers representing the contractor or subcontractor,
as the case may be,

___________________________________________________
Name of workers’ representatives who shall come from the union, if
the workers are organized, or elected workers through a simple vote of
majority, if unorganized.

(c) Joint Coordinating Committee: For two (2) or more establishments housed
under one building or complex including malls.

Chairperson : ________________________________________________
Name of Building owner or his/her representative such as the
building administrator

Secretary : _________________________________________________
Name of Safety officer appointed by the Chairperson

Members : __________________________________________________

Name of 2 safety officers from the building selected to the

Joint OSH Committee

__________________________________________________
__________________________________________________
Name of two (2) workers’ representatives one from which must
be from a union if organized from any establishments under
the building

(All members of the HSC shall perform their duties and responsibilities by the OSH
law and its implementing guidelines.)

Safety and Health Committee Minutes/Reports submitted to DOLE (pls attach latest
OSH committee minutes/report)

Yes ____ No ______

6.0 OSH Personnel and Facilities

6.1 Safety Officer

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 Safety Officer(s): (attach certificate of training/s prescribed by DOLE) (please
use additional sheets as necessary)

Name of Safety Officer(s): Training(s) (kindly include number of

hours)

6.2 Emergency Occupational Health Personnel and Facilities

List of competent emergency health personnel within the worksite duly

complemented by adequate medical supplies, equipment and facilities based on the
total number of workers. (Use additional sheet if necessary and attach all required
training certificates in this section.)
Emergency Health Personnel and Facilities

Health Personnel & Facilities

Total number of Health Personnel (First- Facilities
Shift/Area/unit/
workers/area aider, Nurse, Physician, (Treatment Room/
Department
Dentist) Clinic/ Hospital)

7.0 Safety and Health Promotion, training and education provided to

workers

- Orientation of all workers on OSH

- Conduct of Risk Assessment, evaluation, and Control
- *Continuing training on OSH for OSH Personnel
- *Work permit System
*(Applicable for medium to high-risk establishments with 10 to
50 workers and low to high-risk establishments with 51
workers and above)

(Please attach additional sheets as necessary)

Name of OSH Training / Number of Employees in

Date
Orientation Attendance

Conduct of Risk Assessment

Date
(may include WEM)

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8.0 Conduct of Toolbox Meetings/ Safety Meetings if applicable

Conduct of Safety Meetings/Toolbox

Date
Meetings

9.0 Accident/Incident/Injury investigation recording and reporting

Any dangerous occurrence, major accident resulting to death or permanent total

disability, shall be reported by the company to the DOLE Regional Office within
twenty-four (24) hours from occurrence using the prescribed form (Work Accident /
Incident Notification).

After the conduct of investigation, the company shall prepare and submit work
accident report using the prescribed form (WAIR). Moreover, other work accidents
resulting to disabling injuries such as Permanent Partial Disability and Temporary
Total Disability shall be reported to the DOLE Regional Office within 30 days after the
date of occurrence of accident using the DOLE prescribed form (WAIR).

All near misses shall be recorded and reported. A system for notification and
reporting of work accidents including near misses within the company shall be
developed and reviewed by the OSH Committee as necessary.

(Kindly submit reports on the following: Work Accident /Injury Report (WAIR),
Annual Exposure Data Report (AEDR), Annual Medical Report (AMR)
Report Submitted Date

10.0 Provision and use of PPE

Issuance of PPE shall be supplemented by training on the application, use, handling,

cleaning, and maintenance.

Number of Workers Provided with

PPE Provided
PPE

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11.0 Safety Signage
The safety signages include warning to workers and employees and the public about
the hazards within the workplace.

Type of Safety Signage: Kindly attach picture.

12.0*Dust control and management and regulation on activities such as

building of temporary structures and lifting and operation of electrical,
mechanical, communications system and other requirements *(Applicable for
medium to high-risk establishments with 10 to 50 workers and low to high-risk
establishments with 51 workers and above)

Kindly attach dust control procedures, plans on temporary structures, permits

applicable for the operation of electrical, mechanical, communications systems
and other requirements

13.0 Workers Facilities Provided:

PROVIDED? REMARKS
FACILITIES
YES NO
a. Adequate supply of drinking water
b. Adequate sanitary and washing
facilities
c. Suitable living accommodation (if
applicable)
d. Separate sanitary, washing and
sleeping facilities (if applicable)
e. Lactation station (in consonance
with DOLE D.O. 143-15)
f. Ramps, railings, and the like
g. Other workers’ welfare facilities as
prescribed by OSHS and other
related issuances

14.0 Emergency and Disaster Preparedness:

14.1 Written Emergency and Disaster Program Yes____
No_____

14.2 Types and number of Drills conducted

Type of Drills (fire, Date Responsible

earthquake) person/position

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 15.0 Solid Waste Management System
Written Pollution Control Program: Yes: ____ No: _____

Name of Pollution Control Officer: __________________________

16.0Compliance with Reportorial Government Requirements (refer to item 9.0)

17.0 Control and management of hazards.

Refer to accomplished HIRAC

18.0 *Prohibited Acts and Penalties/sanctions for violations on OSH

*(Applicable for medium to high-risk establishments with 10 to 50 workers and low to
high risk establishments with 51 workers and above)

(Pls attach existing company sanctions for violations on OSH)

(Example of Company violation policies)

Safety Violation 1st offense 2nd offense 3rd offense
1. Not using issued PPE warning 3-day suspension 5-day
suspension
2. littering and loitering warning 3-day suspension 5-day
suspension
3. smoking at prohibited area warning 3-day suspension 5-day
suspension
4. illegal dismantling of safety warning 3-day suspension 5-day
signages and suspension
paraphernalia
5. Not following safety rules 3-day 5-day suspension Dismissal
suspension

19.0 * Cost of implementing company OSH program

*(Applicable for medium to high-risk establishments with 10 to 50 workers and low to
high-risk establishments with 51 workers and above)

Php _______; Annual estimated amount for OSH program implementation to include
but not limited to the following: orientation/training of workers, safety officer, OH
personnel, purchase and maintenance of PPE, first aid medicine and other medical
supplies, safety signages and devices, fire safety equipment/tools, safety of
equipment (i.e. machine guards, etc.)

OSH Item Estimated Cost/year

PPEs

OSH trainings

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 Safety Signages

Machine Guards and related

equipment

Medical examinations

Medical supplies/medicines

Others: Specify

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ANNEX A:

WORKPLACE POLICY AND PROGRAM ON PROMOTING WORKERS HEALTH

AND ENSURING PREVENTION AND CONTROL OF HEALTH-RELATED ISSUES
AND ILLNESS

_____________________________________ company is committed to

promote and ensure a healthy and safe working environment through its various
health programs for its employees. We shall conform to all issuances and laws that
guarantee workers health and safety at all times.

The company shall ensure that worker’s health is maintained through the
following company programs and activities:
a) Orientation and education of employees
b) Access to reliable information on illness and hazards at work
c) Referral to medical experts for diagnosis and management of illness or
health-related concerns
d) Provide health-related programs such proper nutrition and exercise
activities are made available to the workers

The above-mentioned programs shall comply with the Government’s

issuances on promoting healthy lifestyle, addressing mental health in the
workplace, and preventing and controlling substance abuse.

In addition, company policies to protect workers’ rights arising from illness shall be
guaranteed. The company shall promote the following workers’ rights:
a) Confidentiality of information
b) Non-discrimination including non-termination
c) Work accommodation following a course of illness
d) Assistance to compensation

This policy is formulated for everybody’s information. The company is

committed to ensuring workers’ health and providing a healthy and safe workplace.

______________________ ___________________________
Owner /Manager Employees’ Representative

DATE: ______________

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