REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF LABOR AND EMPLOYMENT

RKSForm5
2009

______________________________
Fieldoffice/RegionalOffice

Page1of___
pages

Instructions:
1. Accomplishthisformintwocopieswhenfillingnoticeofdisplacementofflexibleworkarrangements.The
reportisconsideredasdullyfilledwhenthecompletelistofworkersaffectedismadepartofthesubmission.
2. ThisformshouldbesubmittedtotheDOLEFieldOffice30calendardayspriortoaffectivityof
displacement/adoptionofflexibleworkarrangements.
3. Page1shouldcontaingeneralinformationabouttheestablishmentandthenumberofworkersaffected.
4. Page2shouldenumeratethenamesofworkersaffectedandtheiraddressesandcontactnumbers.
5. Totalnumbersofworkerslistedshouldequalthetotalnumberofworkersaffectedasreportedinthispage.

ESTABLISHMENTEMPLOYMENTREPORT
A. EstablishmentData:
NameofEstablishment_____________________________________________________________________________
Floor/Bldg./No./Street/Subdivision_____________________________________________________________________
_________________________________________________________________________________________________
Barangay/City/Municipality___________________________________________________________________________
ZipCode/Province_________________________________________________GEOCODEl__I__I__I__I__I__I__I__I__l
MainEconomicActivity(Specifyproducts/goods/services)__________________________________________________
___________________________________________________________________________PSICl__l__l__l__l__l__l
TotalEmployment: NoofFemaleWorkers:
Dateoffilling:(mm/dd/yyyy)l__l__l__l__l__l__l__l__l
1.EstablishmentStatus:(pleasecheckapplicablestatus)
[]PermanentClosure[]TemporaryClosure
[]ReductionofWorkforce[]FlexibleWorkArrangements
2.MainreasonforShutdown/RetrenchmentofWorkers(usecodebelow,selectonlyone):_________________
3.Istheclosure/reductionofworkforce/flexibleworkarrangementsasaconsequenceof:
[]GlobalCrisis[]Others(specify)______________________________________________
B. WorkersAffectedbyDisplacement/FlexibleWorkArrangements

EffectivityDate
Indicator
No.ofWorkers
From
To

Affected
(mm/dd/yyyy)
(mm/dd/yyyy)
1. PermanentTerminations

2. TemporaryLayoffs

3. FlexibleWorkArrangements

3.1RotationofWorkers

3.2ReducedWorkhours/Workdays

3.3ForcedLeave

CodesforMainReasonforShutdown/RetrenchmentofWorkers:
EconomicReasons
LMCancellationoforders/
Lackofmarket/Slumpin
Demand
LCLackofcapital
HCPHighcostofproduction
RRedundancy
CMMChangeinmanagement/
Merger
RDSCompanyreorganization/
Downsizing

NonEconomicReasons
PC ProjectCompletion
NCLNaturalCalamities(fire,
AWOLAbsencewithoutLeave typhoon,etc.)
LLDACeasedandDesistOrder
SMSeriousMisconduct
NRMRepair/General
GHNGrossHabitualNeglect Maintenance

CCOCommissionofacrime INVInventory
orOffense
FDLForcedLeave
RESResigned
FUDFraud
RETRetirement

OTHSothers
(pleasespecify)____________
_________________________

CICompetitionfrom
Importedproducts
UCPUncompetitivepriceof
product
MRIncreaseinminimum
wagerate
LRMLackofrawmaterials
PDPesodevaluation/
appreciation
OTHothers(specify)

CERTIFICATION
Thisistocertifyastotheaccuracyofthedataprovidedinthisreport.
Name/SignatureofOwner/
CompanyRepresentative:
Position:
Tel.No.:

FaxNo.:
EmailAddress:

REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF LABOR AND EMPLOYMENT

RKSForm5
2009

______________________________
Fieldoffice/RegionalOffice

Page2of___
Pages

Instructions:Useadditionalsheetsifnecessaryfollowingsameformat.

LISTOFAFFECTEDWORKERSBYDISPLACEMENTS/
FLEXIBLEWORKARRANGEMENTS
No.

NameofWorker
(LastName,FirstName,M.I)

Address

Contact
Number/s

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.

CodesforTypeofDisplacements/FlexibleWorkArrangements:
1.
2.
3.
4.

PermanentTermination
TemporaryLayoff
RotationofWorkers
ReducedWorkhours/Workdays

Typeof
Displacements/
FlexibleWork
Arrangements
(usecodebelow)