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    FORM - Dole Employer's Work Accident Illness Report

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    shirleyaquino675

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    © All Rights Reserved
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    FORM - Dole Employer's Work Accident Illness Report

    Uploaded by

    shirleyaquino675
    64 views6 pages

    Copyright

    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Download as xls, pdf, or txt
    64 views6 pages

    FORM - Dole Employer's Work Accident Illness Report

    Uploaded by

    shirleyaquino675

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Download as xls, pdf, or txt
    of 6

    DOLE/ BWC/ IP-6 Form

    Republic of the Philippines


    Department of Labor and Employment
    BUREAU OF WORKING CONDITIONS
    Region IV-A

    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: Republic Cement & Building Materials Inc. (RCBMI)/ Tonijon Construction
    2 Address: Barrio Mapulo, Taysan, Batangas
    EMPLOYER
    3 Name of Employer: Tonijon Construction- Alfredo Mercado
    4 No. of Employees: Male: 69 Female: 3 Total: 72

    5 Name: Ramel Cueto Age: 43 Sex: Male Civil Status: Married


    INJURED OR 6 Address: PiÑa, Taysan, Batangas
    ILL PERSON 7 Average Weekly Wage: PHP 2, 160 No. of Dependents: 3
    8 Length of Service Prior to Accident / Illness: 6 years and 5 months

    OCCUPA - 9 Occupation: Safety Officer Experience at Occupation: 1 year and 3 months


    TIONAL
    10 Work Shift: Day Shift 1st ___ 2nd____ 3rd_ Hours of Work / Day: 8 hours Days / Week: 6 days
    HISTORY

    11 Date of Accident / Illness: September 6, 2016 Time: 1:50 pm


    12 Accident Involved: 1 employee Personal Injury: 1 Fatal Property Damage: none
    13 Description of Accident:
    Contractor Employee Hit by Fallen Debris (Please see attached Incident Notification for further details)
    ACCIDENT/
    ILLNESS

    14 Was injured doing regular part of job at the time of accident or illness, if not, why? No
    Because the group of Mr. Ramel Cueto has finish their activity (cement pouring of piping cooling system)
    at the area. They were taking their shelter at the Finish Mill Area.

    15 Extent of Disability: not applicable Fatal: 1 Permanent Total: not applicable


    Permanent Partial: n/a Temporary Total: n/a Medical Treatment: n/a
    NATURE & 16 Nature of Injury or Illness: 8.0 cm Lacerated wound with open skull fracture on frontal lobe; Depressed
    EXTENT OF and palpable skull fracture on ocipital lobe; 8.0 inches long gaping lacerated wound on left leg with
    INJURY / open fracture
    ILLNESS Parts of Body Affected: frontal and ocipital lobes of skull; left leg
    17 Date Disability Begun: September 6, 2016 Date Returned to Work: N/A
    18 Days Lost: N/A or Days Charged: 6000 days

    19 The Agency Involved: Roofing gutter with debris


    20 The Agency Part Involved: Cement debris
    CAUSE OF 21 Accident type: Fatality
    ACCIDENT /
    22 Unsafe Mechanical or Physical Condition: Presence of debris on roofing gutter
    ILLNESS
    23 The Unsafe Act: N/A
    24 Contributing Factor: Heavy rain; Power outage; Accumulated cement build up
    25 Preventive Measures (taken or recommended): 1. Identification and mapping of structures with cement
    build-up; 2. Removal of build-up on identified structures; 3. Removal of unsafe gutters at the plant
    4. Reinforce existing gutters that have no support
    PREVENTIVE
    MEASURES
    26 Mechanical guards, personal protective equipment and other safeguards provided: Immediately
    installed scaffolding shelter on critical areas
    27 Were all safeguards in use? yes If not, why? Not applicable
    28 Compensation: PHP 360/ day
    29 Medical and Hospitalization: Not Applicable
    30 Burial: PhP 65,000
    MANPOWER 31 Time Lost on Day of Injury: Days: 6000 days Hours: 0 Minutes: 0
    32 Time Lost on Subsequent Days: Hours: 0 Minutes: 0
    33 Time on light work or reduced output: Not Applicable Days: 0 Hours: 0

    34 Damage to Machinery and Tools (Describe): Not Applicable


    MACHINERY 35 Cost of Repair or replacement: Not Applicable
    AND TOOLS
    36 Lost production time: Not Applicable Cost: Not Applicable

    37 Damage to Materials (Describe): Not Applicable


    MATERIALS 38 Cost of Repair or replacement: PHP 187,800
    39 Lost production time: 9 days Cost: Not Applicable

    40 Damage to Equipment (Describe): Not applicable


    EQUIPMENT 41 Cost of Repair or replacement: Not Applicable
    42 Lost production time: Not Applicable Cost: Not Applicable

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

    EDWARD IAN B. CIPRIANO/ RCBMI/ H&S Manager ALFREDO A. MERCADO


    Signature over Printed Name of Employer
    Investigating Officer and Position

    Date

    Note: To be accomplished in triplicate


    DOLE/ BWC/ IP-6 Form

    Republic of the Philippines


    Department of Labor and Employment
    BUREAU OF WORKING CONDITIONS
    Region IV-A

    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: Republic Cement & Building Materials Inc. (RCBMI)/ Tonijon Construction
    2 Address: Barrio Mapulo, Taysan, Batangas
    EMPLOYER
    3 Name of Employer: Tonijon Construction- Alfredo Mercado
    4 No. of Employees: Male: 69 Female: 3 Total: 72

    5 Name: Renato An Age: 52 Sex: Male Civil Status: Married


    INJURED OR 6 Address: Sto. Nino, Taysan, Batangas
    ILL PERSON 7 Average Weekly Wage: PHP 2, 340 No. of Dependents: 1
    8 Length of Service Prior to Accident / Illness: 1 year and 2 months

    OCCUPA - 9 Occupation: Welder Experience at Occupation: 27 years


    TIONAL
    10 Work Shift: Day Shift 1st ___ 2nd____ 3rd_ Hours of Work / Day: 8 hours Days / Week: 6 days
    HISTORY

    11 Date of Accident / Illness: September 6, 2016 Time: 1:50 pm


    12 Accident Involved: 1 employee Personal Injury: 1 LTI Property Damage: none
    13 Description of Accident:
    Contractor Employee Hit by Fallen Debris (Please see attached Incident Notification for further details)
    ACCIDENT/
    ILLNESS

    14 Was injured doing regular part of job at the time of accident or illness, if not, why? No
    Because the group of Mr. Renato An has finish their activity (painting of piping cooling system)
    at the area. They were taking their shelter at the Finish Mill Area.

    15 Extent of Disability: not applicable Fatal: n/a Permanent Total: not applicable
    Permanent Partial: n/a Temporary Total: 1 Medical Treatment: n/a
    NATURE & 16 Nature of Injury or Illness: Closed Fracture Posterior 1st to 3rd left ribs; Blunt trauma posterior
    EXTENT OF chest wall; pulmonary contusion; compression T6, T7 and T9 vertebral bodies
    INJURY /
    ILLNESS
    17 Date Disability Begun: September 6, 2016 Date Returned to Work: TBD
    18 Days Lost: TBD or Days Charged: N/A

    19 The Agency Involved: Roofing gutter with debris


    20 The Agency Part Involved: Cement debris
    CAUSE OF 21 Accident type: Fatality
    ACCIDENT /
    22 Unsafe Mechanical or Physical Condition: Presence of debris on roofing gutter
    ILLNESS
    23 The Unsafe Act: N/A
    24 Contributing Factor: Heavy rain; Power outage; Accumulated cement build up
    25 Preventive Measures (taken or recommended): 1. Identification and mapping of structures with cement
    build-up; 2. Removal of build-up on identified structures; 3. Removal of unsafe gutters at the plant
    4. Reinforce existing gutters that have no support
    PREVENTIVE
    MEASURES
    26 Mechanical guards, personal protective equipment and other safeguards provided: Immediately
    installed scaffolding shelter on critical areas
    27 Were all safeguards in use? yes If not, why? Not applicable
    28 Compensation: PHP 390/ day
    29 Medical and Hospitalization: PHP 143,082.95
    30 Burial: Not Applicable
    MANPOWER 31 Time Lost on Day of Injury: Days: TBD Hours: 0 Minutes: 0
    32 Time Lost on Subsequent Days: Hours: TBD Minutes: 0
    33 Time on light work or reduced output: TBD Days: 0 Hours: 0

    34 Damage to Machinery and Tools (Describe): Not Applicable


    MACHINERY 35 Cost of Repair or replacement: Not Applicable
    AND TOOLS
    36 Lost production time: Not Applicable Cost: Not Applicable

    37 Damage to Materials (Describe): Not Applicable


    MATERIALS 38 Cost of Repair or replacement: PHP 187,800
    39 Lost production time: 9 days Cost: Not Applicable

    40 Damage to Equipment (Describe): Not applicable


    EQUIPMENT 41 Cost of Repair or replacement: Not Applicable
    42 Lost production time: Not Applicable Cost: Not Applicable

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

    EDWARD IAN B. CIPRIANO/ RCBMI/ H&S Manager ALFREDO A. MERCADO


    Signature over Printed Name of Employer
    Investigating Officer and Position

    Date

    Note: To be accomplished in triplicate

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