DOLE/BWC/OHSD/IP-6

Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT
Region I

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: ORO OXYGEN CORPORATION

2. Address: STA.BARBARA, PANGASINAN
3. Nature of Business: LPG REFILLING PLANT
EMPLOYER 4. Name of Employer: JULIUS H. CUADY IV Nationality: FILIPINO
5. No. of Employees: Male: _____15______ Female: ____NA______ Total __15___

6. Name : __NONE_________ Age: _N/A__Sex: _ N/A Civil Status:__ N/A ____

INJURED OR 7. Address: _____ N/A __________________________________________________
ILL PERSON 8. Average Weekly Wage: P_ N/A __________ No. of Dependents: ___ N/A ________
9. Length of service prior to accident or illness: ________ N/A ___________________
Occupational 10. Occupation: __ N/A ____________ Experience at Occupation: _ N/A ___________
History 11. Work Shift: _N/A 1st N/A 2nd N/A _3rd Hours of work/day: N/A _ Day/Week:_ N/A __
12. Date of accident/illness: __ N/A ________________ Time: N/A _____________
13. The accident involved: ____ N/A _____ Personal Injury: __ N/A _____________
Property Damage: __ N/A _____________
ACCIDENT 14. Description of accident/illness (Give full details on how accident or illness
OR occurred): ___ N/A _________________________________________________
ILLNESS _______ N/A ______________________________________________________
15. Was injured doing regular part of job at the time of accident or illness:
If not, why? ___________ N/A ________________________________________
16. Extent of Disability: N/A Fatal _ N/A _____ Permanent Total __ N/A _______
NATURE &
Permanent Partial: _ N/A __Temporary Total _ N/A __ Medical Treatment N/A ___
EXTENT OF
17. Nature of Injury or Illness: __ N/A _______ Parts of body affected: __ N/A ______
INJURY OR
18. Date Disability Begun: _ N/A _________ Date Returned to Work: _ N/A ________
ILLNESS
19. Days Lost: _ N/A ______________ or Days Charged: ___ N/A _____________

20. The Agency Involved: __ N/A ________________________________________

CAUSE OF 21. The Agency Part Involved: _________ N/A ______________________________
ACCIDENT 22. Accident Type: _______________________________ N/A _________________
OR ILLNESS 23. Unsafe Mechanical or Physical Condition: _ N/A __________________________
24. The Unsafe Act: _ N/A ______________________________________________
25. Contributing Factor: ____________ N/A _________________________________
26. Preventive Measures (taken or recommended): __ N/A ______________________
27. Mechanical guards, personal protective equipment and other safeguards
PREVENTIVE
provided: _____ N/A ________________________________________________
MEASURES
28. Were all safeguards in used? _ N/A ___ If not, why? __ N/A _________________
__________________________________________________________________
29. Compensation: __ N/A ___ P __ N/A _________________________________
30. Medical & Hospitalization: __ N/A _______________________________________
31. Burial: __________ N/A ______________________________________________
32. Time lost on day of injury: N/A _______ Hrs. _ N/A ______ Mins. _ N/A _________
MANPOWER
33. Time lost on subsequent days: N/A __ Hrs. _ N/A ______ Mins. N/A ___________
(Treatment or other reasons)
34. Time on light work or reduced output: __ N/A _____ Day: ____ N/A ___________
Percent Output: ___ N/A _________________
35. Damage to Machinery and Tools (Describe): ___ N/A _______________________
MACHINERY
36. Cost of repair or replacement: __ N/A __________________________________
AND TOOLS
37. Lost Production Time: ___ N/A _________________ Cost: ___ N/A ____________
38. Damage to Materials (Describe): ___ N/A _______________________________
MATERIALS 39. Cost of repair or replacement: __ N/A _________________________________
40. Lost Production Time: ______ N/A ______________ Cost: ____ N/A __________
41. Damage to Equipment (Describe): __ N/A ________________________________
EQUIPMENT 42. Cost of repair or replacement: ______ N/A ________________________________
43. Lost production time: _________ N/A ____________________________________
I HEREBY CERTIFY on my honor to the accuracy of the foregoing information:

JANUARY 8, 2019
Date

MARK ARTEM APALLA_/ Plant Supervisor PETER M. CAUSIN

Investigating Officer & Position POM/Employer