78%(18)78% ont trouvé ce document utile (18 votes)
10K vues1 page
This employer's work accident/illness report indicates that there were no accidents or illnesses to report. All fields are marked "N/A" (not applicable) to indicate that no injured or ill person, accident details, causes, preventive measures, compensation or costs are relevant as there was no accident or illness. The report is being submitted as required on or before the 20th day of the month following any accident or illness, but in this case, none occurred at the covered establishment.
This employer's work accident/illness report indicates that there were no accidents or illnesses to report. All fields are marked "N/A" (not applicable) to indicate that no injured or ill person, accident details, causes, preventive measures, compensation or costs are relevant as there was no accident or illness. The report is being submitted as required on or before the 20th day of the month following any accident or illness, but in this case, none occurred at the covered establishment.
This employer's work accident/illness report indicates that there were no accidents or illnesses to report. All fields are marked "N/A" (not applicable) to indicate that no injured or ill person, accident details, causes, preventive measures, compensation or costs are relevant as there was no accident or illness. The report is being submitted as required on or before the 20th day of the month following any accident or illness, but in this case, none occurred at the covered establishment.
(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___
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