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    Employer's Work Accident Report - NCR

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    Calpo Omel
    This document is an employer's work accident/illness report submitted to the Department of Labor and Employment in the Cagayan Valley region of the Philippines. It collects information about an accident or illness, including details of the injured employee, their occupation, a description of the incident, the nature and extent of any injuries, causes of the accident/illness, preventive measures taken, and impacts to manpower, machinery/tools, materials, and equipment. The report is to be submitted by the employer within 20 days of an accident or illness occurring.

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    © All Rights Reserved
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    Employer's Work Accident Report - NCR

    Uploaded by

    Calpo Omel
    194 views1 page
    This document is an employer's work accident/illness report submitted to the Department of Labor and Employment in the Cagayan Valley region of the Philippines. It collects information about an accident or illness, including details of the injured employee, their occupation, a description of the incident, the nature and extent of any injuries, causes of the accident/illness, preventive measures taken, and impacts to manpower, machinery/tools, materials, and equipment. The report is to be submitted by the employer within 20 days of an accident or illness occurring.

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    This document is an employer's work accident/illness report submitted to the Department of Labor and Employment in the Cagayan Valley region of the Philippines. It collects information about an accident or illness, including details of the injured employee, their occupation, a description of the incident, the nature and extent of any injuries, causes of the accident/illness, preventive measures taken, and impacts to manpower, machinery/tools, materials, and equipment. The report is to be submitted by the employer within 20 days of an accident or illness occurring.

    Copyright:

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

    Employer's Work Accident Report - NCR

    Uploaded by

    Calpo Omel
    This document is an employer's work accident/illness report submitted to the Department of Labor and Employment in the Cagayan Valley region of the Philippines. It collects information about an accident or illness, including details of the injured employee, their occupation, a description of the incident, the nature and extent of any injuries, causes of the accident/illness, preventive measures taken, and impacts to manpower, machinery/tools, materials, and equipment. The report is to be submitted by the employer within 20 days of an accident or illness occurring.

    Copyright:

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

    Republic of the Philippines

    DEPARTMENT OF LABOR AND EMPLOYMENT


    Cagayan Valley (Region II)
    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.)
    1. Establishment: ______________________________________________________
    2. Address: ___________________________________________________________
    3. Nature of Business:___________________________________________________
    EMPLOYER 4. Name of Employer: ____________________ Nationality: _____________________
    5. No. of Employees: Male: __________ Female: __________Total: __________

    6. Name : ________________________ Age: ____Sex: ____ Civil Status:_________


    INJURED OR 7. Address: ___________________________________________________________
    ILL PERSON 8. Average Weekly Wage: P_______________ No. of Dependents: _______________
    9. Length of service prior to accident or illness: _______________________________
    Occupational 10. Occupation: __________________ Experience at Occupation: ________________
    History 11. Work Shift: ____1st ____2nd ____3rd Hours of work/day: _____ Day/Week:_______
    12. Date of accident/illness: _______________________ Time: __________________
    13. The accident involved: ______________ Personal Injury: ____________________
    Property Damage: ____________________
    ACCIDENT
    14. Description of accident/illness (Give full details on how accident or illness
    OR
    occurred): ________________________________________________________
    ILLNESS
    15. Was injured doing regular part of job at the time of accident or illness:
    If not, why? ________________________________________________________
    16. Extent of Disability: ____ Fatal ____________ Permanent Total _______________
    NATURE &
    Permanent Partial: _______Temporary Total _______ Medical Treatment ______
    EXTENT OF
    17. Nature of Injury or Illness: _____________ Parts of body affected: _____________
    INJURY OR
    18. Date Disability Begun: _______________ Date Returned to Work: _____________
    ILLNESS
    19. Days Lost: ____________________ or Days Charged: _____________________

    20. The Agency Involved: ________________________________________________


    CAUSE OF 21. The Agency Part Involved: ____________________________________________
    ACCIDENT 22. Accident Type: _____________________________________________________
    OR ILLNESS 23. Unsafe Mechanical or Physical Condition: ________________________________
    24. The Unsafe Act: ____________________________________________________
    25. Contributing Factor: _________________________________________________

    26. Preventive Measures (taken or recommended): ____________________________


    PREVENTIVE 27. Mechanical guards, personal protective equipment and other safeguards
    MEASURES provided: __________________________________________________________
    28. Were all safeguards in used? ________ If not, why? ________________________

    29. Compensation: __________ P _________________________________________


    30. Medical & Hospitalization: _____________________________________________
    31. Burial: ____________________________________________________________
    32. Time lost on day of injury: __________ Hrs. ___________ Mins. ______________
    MANPOWER
    33. Time lost on subsequent days: ______ Hrs. ___________ Mins. ______________
    (Treatment or other reasons)
    34. Time on light work or reduced output: ___________ Day: ___________________
    Percent Output: _________________________
    35. Damage to Machinery and Tools (Describe): ______________________________
    MACHINERY
    36. Cost of repair or replacement: _________________________________________
    AND TOOLS
    37. Lost Production Time: ________________________ Cost: __________________
    38. Damage to Materials (Describe): _______________________________________
    MATERIALS 39. Cost of repair or replacement: __________________________________________
    40. Lost Production Time: ________________________ Cost: ___________________
    41. Damage to Equipment (Describe): ______________________________________
    EQUIPMENT 42. Cost of repair or replacement: __________________________________________
    43. Lost production time: _________________________________________________

    I HEREBY CERTIFY on my honor to the accuracy of the foregoing information:


    ___________________________
    Date
    ____________________________ _________________________
    Investigating Officer & Position Employer

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