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    WAIR

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    Alaine Sobredo
    1) The document is an employer's work accident/illness report submitted by BLAC Prime Construction Inc. for the month of January 2022. However, no accident or illness was reported, as all details provided are marked "NA". 2) BLAC Prime Construction Inc. is a fit-out construction company located in Pasig City with 35 employees, but no injuries were recorded for the reporting month. 3) All sections of the report seeking description of accident/illness, nature and extent of injury, cause of accident, preventive measures, manpower/machinery/materials/equipment losses are marked "NA", indicating no accident took place.

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    WAIR

    Uploaded by

    Alaine Sobredo
    205 views1 page
    1) The document is an employer's work accident/illness report submitted by BLAC Prime Construction Inc. for the month of January 2022. However, no accident or illness was reported, as all details provided are marked "NA". 2) BLAC Prime Construction Inc. is a fit-out construction company located in Pasig City with 35 employees, but no injuries were recorded for the reporting month. 3) All sections of the report seeking description of accident/illness, nature and extent of injury, cause of accident, preventive measures, manpower/machinery/materials/equipment losses are marked "NA", indicating no accident took place.

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    1) The document is an employer's work accident/illness report submitted by BLAC Prime Construction Inc. for the month of January 2022. However, no accident or illness was reported, as all details provided are marked "NA". 2) BLAC Prime Construction Inc. is a fit-out construction company located in Pasig City with 35 employees, but no injuries were recorded for the reporting month. 3) All sections of the report seeking description of accident/illness, nature and extent of injury, cause of accident, preventive measures, manpower/machinery/materials/equipment losses are marked "NA", indicating no accident took place.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    205 views1 page

    WAIR

    Uploaded by

    Alaine Sobredo
    1) The document is an employer's work accident/illness report submitted by BLAC Prime Construction Inc. for the month of January 2022. However, no accident or illness was reported, as all details provided are marked "NA". 2) BLAC Prime Construction Inc. is a fit-out construction company located in Pasig City with 35 employees, but no injuries were recorded for the reporting month. 3) All sections of the report seeking description of accident/illness, nature and extent of injury, cause of accident, preventive measures, manpower/machinery/materials/equipment losses are marked "NA", indicating no accident took place.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    DOLE/BWC/OHSD/IP-6a

    Republic of the Philippines


    DEPARTMENT OF LABOR AND EMPLOYMENT
    Bureau of Working Condition
    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 occurrence.) For the month of January 2022

    1. Establishment:The Imperium at Capitol Commons.


    2. Address: Camino Verde Rd. Pasig City
    3. Nature of Business: Fit-Out Construction
    EMPLOYER 4. Name of Employer: BLAC Prime Construction Inc. Nationality: NA
    5. No. of Employees: Male: 30 Female: _5_ Total: 35
    6. Name : ________NA________________ Age: __NA__Sex: __NA__ Civil
    Status:_____NA__
    7. Address: _____________NA_______________________________________
    INJURED OR
    8. Average Weekly Wage: NA No. of Dependents: NA .
    ILL PERSON
    9. Length of service prior to accident or illness: ___________NA_________________
    10. Occupation: _NA____________ Experience at Occupation: ________________
    Occupational
    11. Work Shift: _√___1st ____2nd ____3rd Hours of work/day: _____
    History
    Day/Week:_6______

    12. Date of accident/illness: ____NA________________ Time: ____NA____________


    13. The accident involved: _____NA_______ Personal Injury: ________NA_________
    Property Damage: ________NA_________
    ACCIDENT 14. Description of accident/illness (Give full details on how accident or illness
    OR occurred): _______NA________________________________________________
    ILLNESS _________________________________________
    15. Was injured doing regular part of job at the time of accident or illness:
    If not, why? _______NA__________________________________________
    16. Extent of Disability: __NA Fatal ___NA______ Permanent Total _______NA_____
    NATURE &
    Permanent Partial: ___NA_ Temporary Total ___NA__ Medical Treatment __NA
    EXTENT OF
    17. Nature of Injury or Illness: ____NA______ Parts of body affected: ______NA____
    INJURY OR
    18. Date Disability Begun: _____NA_______ Date Returned to Work: _____NA______
    ILLNESS
    19. Days Lost: ____NA______________ or Days Charged: _______NA___________

    20. The Agency Involved: ___________NA__________________________________


    CAUSE OF 21. The Agency Part Involved: _____________NA____________________________
    ACCIDENT 22. Accident Type: _____________________________NA______________________
    OR ILLNESS 23. Unsafe Mechanical or Physical Condition: _____________NA_________________
    24. The Unsafe Act: _____________________________________NA________
    25. Contributing Factor: ___________________NA____________________________
    26. Preventive Measures (taken or recommended): ____________________________
    27. Mechanical guards, personal protective equipment and other safeguards
    PREVENTIVE
    provided: _________________NA______________________________________
    MEASURES
    28. Were all safeguards in used? ___NA__ If not, why? _________NA_____________
    __________________________________________________________________
    29. Compensation: ____NA____ _________________NA___________________
    30. Medical & Hospitalization: _________NA_________________________________
    31. Burial: _________________NA_________________________________________
    32. Time lost on day of injury: ___NA_____ Hrs. ____NA____ Mins. ____NA________
    MANPOWER
    33. Time lost on subsequent days: __NA__ Hrs. ____NA___ Mins. ____NA_______
    (Treatment or other reasons)
    34. Time on light work or reduced output: __NA_______ Day: ____NA_____
    Percent Output: ___________NA_______
    35. Damage to Machinery and Tools (Describe): ____________NA_______________
    MACHINERY
    36. Cost of repair or replacement: _________NA______________________________
    AND TOOLS
    37. Lost Production Time: _______NA_______________ Cost: _________NA_______
    38. Damage to Materials (Describe): ________NA_____________________________
    MATERIALS 39. Cost of repair or replacement: ________________NA_______________________
    40. Lost Production Time: _______NA______________ Cost: ________NA_________
    41. Damage to Equipment (Describe): _____NA_______________________________
    EQUIPMENT 42. Cost of repair or replacement: __________________NA_____________________
    43. Lost production time: ____________NA__________________________________
    I HEREBY CERTIFY on my honor to the accuracy of the foregoing information:
    February 18, 2022
    Date
    ENGR. ALAINE G. SOBREDO MARK S. JASARINO
    Safety Engineer Project-in-Charge

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