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1) The document is an employer's work accident/illness report submitted by BLAC Prime Construction Inc. to the Department of Labor and Employment for the month of January 2022. 2) However, the report does not contain any information about a specific accident or injured employee, as all fields are marked "NA" (not applicable). 3) The report appears to be a blank/template form submitted because it is required to be filed each month, even when there are no accidents to report.

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Alaine Sobredo
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241 views

Ewair

1) The document is an employer's work accident/illness report submitted by BLAC Prime Construction Inc. to the Department of Labor and Employment for the month of January 2022. 2) However, the report does not contain any information about a specific accident or injured employee, as all fields are marked "NA" (not applicable). 3) The report appears to be a blank/template form submitted because it is required to be filed each month, even when there are no accidents to report.

Uploaded by

Alaine Sobredo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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: 24 Female: _3__ Total: 27
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____ P _________________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:
January 28, 2022
Date
ENGR. ALAINE G. SOBREDO MARK S. JASARINO
Safety Engineer Project-in-Charge

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