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					Republic of the Philippines DEPARTMENT OF LABOR & EMPLOYMENT Region VI, Iloilo City For the month of _______________ 200___ (This shall be submitted by the employer to the regional Office No. 6 every end of the month. Accident which result in death shall be reported within 24 hours from the time of occurrence using the fastest available means of communication). |1. Establishment:__________________________________________________ |2.Address:________________________Nature of Business:________________ |3.Name of Employer: ___________________________Nationality:__________ |4.No. of Employees: ______________Male: _____Female: ____Total:_______ |5.Name:_______________________Age:_____Sex:_____Civil Status: _______ INJURED |6.Address:________________________________________________________ OR ILL PERSON |7.Average Weekly wage: P ____________________No. of Dependents:_______ |8.Length of Service prior to accident or illness:___________________________ OCCUPATIONAL |9.Occupation:_________________Experience at occupation: _______________ HISTORY |10.Work of Shift:___1st:___2nd:___3rd:___Hours of work/day ___ day/Week:___ |11.Date of accident/illness: Date _____________________ Time: ___________ ACCIDENT |12.The accident involved: Personal Injury_____ Property Damage ___Both____ OR |13.Description of accident/illness (Give full details on how accident/illness ILLNESS occurred):_______( Use back page if necessary)_______________________ |14.Was injured doing regular part of job at the time of accident or illness: | If not why?____________________________________________________ |15.Extent of disability: [ ] Fatal [ ] Permanent Total NATURE & EXTENT | [ ] Permanent Temporary Total [ ] Medical Treatment OF INJURY |16.Nature of Injury or Illness:__________ Parts of the Body Affected:________ OR ILLNESS |17.Date disability Begun: ____________Date of Returned to Work___________ |18. Days Lost: _______________________or Days Charge: _______________ |19. The Agency Involved:____________________________________________ |20.The Agency Part Involved:_________________________________________ CAUSE OF |21. Accident Type:_________________________________________________ ACCIDENT OR |22. Unsafe Mechanical or Physical Condition: ____________________________ ILLNESS |23 The Unsafe Act:_________________________________________________ |24. Contributing Factor:_____________________________________________ |25. Prevention Measures ( taken recommended ):_________________________ PREVENTIVE |26. Mechanical Guards, personal protective equipment and other safeguards MEASURES provided: |27. Were all safeguards in use? _________If not , why?___________________ |28. Compensation:_________________________________________________ |29. Medical and Hospitalization:_______________________________________ |30. Burial:________________________________________________________ MANPOWER |31. Time Lost on Day of Injury: _______________Hrs. ______________Minutes |32. Time Lo on Subsequent Days: _____________Hrs. ______________Minutes | (Treatment or other reason) |33. Time on light work or reduced output: Day ________Percent Output:______ |34. Damage to Machinery and Tools (Describe): __________________________ MACHINERY |35. Cost of Repair or Replacement: P___________________________________ |36. Lost Production: Time ___________________Cost_____________________ |37. Damage Materials (Describe): _____________________________________ MATERIALS |38. Cost of Repair or Replacement: P___________________________________ ___________ |39. Lost of Production: Time _________________Cost_____________________ |40. Damage to Machine/s (Describe): __________________________________ EQUIPMENT |41. Cost of Repair or Replacement: P __________________________________ |42. Lost of Production: Time _________________Cost ____________________ EMPLOYER I HEREBY CERTIFY on my honor to the accuracy of the foregoing information. _____________________________ Name & Signature of Owner/Manager _________________ Date

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