DOLE/ BWC/IP-6 Form

Republic of the Philippines

Department of Labor and Employment
Regional Office: _______________

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 20 th day of the month following the date of occurrence.)

1.    Establishment:
2.    Address:
EMPLOYER
3.    Name of Employer:
4.    Number of Employees: Male: Female: Total:

5.    Name: Age: Sex: Civil Status

INJURED OR ILL
PERSON
6.    Address:
7.    Average Weekly Wage: No. of Dependents:
8.    Length of service prior to accident or illness:

OCCUPATIONAL 9.    Occupation: Experience at Occupation:

HISTORY 10.  Work Shift: 1st 2nd 3rd Hours of Work/day: Days/Week

11.  Date of Accident/Illness: Time:

12.  Accident Involved: Personal Injury: Property Damage:
ACCIDENT OR
ILLNESS 13.  Description of Accident:
14.  Was the injured doing regular part of job at time of accident or illness?
If not, why?

15.  Extent of Disability: Fatal Permanent Total Permanent Partial

NATURE AND
EXTENT OF 16.  Nature of injury or illness: Part of the body affected:
INJURY OR
ILLNESS
17.  Date Disability Begun: Date Return to Work:
18.  Days Lost: or Days Charged:

19.  The Agency Involved:

20.  The Agency Part Involved:
CAUSE OF 21.  Accident Type:
ACCIDENT OR
ILLNESS 22.  Unsafe Mechanical or Physical Condition:
23.  Unsafe Act:
24.  Contributing Factor:

25.  Preventive Measures (taken or recommended):

PREVENTIVE
MEASURES 26.  Mechanical guards, personal protective equipment and other safeguards provided:
27.  Were all safeguards in use? If not, why?
 28.  Compensation:
29.  Medical and hospitalization:
30.  Burial:
31.  Time Lost on Day of Injury: Day Hours Minutes
MANPOWER
32.  Time Lost on Subsequent Day Hours Minutes
(treatment or other reason)
33.  Time on light work or reduced output: Day
Percent Output

MACHINERY 34.  Damage to Machinery and Tools (Describe):

AND TOOLS 35.  Cost of Repair or Replacement:
36.  Lost Production Time:

37.  Damaged to Machinery and Tools (Describe):

MATERIALS 38.  Cost of Repair or Replacement:
39.  Lost Production Time: Cost

40.  Damaged to Machinery and Tools (Describe):

EQUIPMENT 41.  Cost of Repair or Replacement:
42.  Lost Production Time: Cost

I HEREBY CERTIFY on my honor to the accuracy of the foregoing information.

Signature over Printed Name of Employer

Investigating Officer and Position

Date

Note: To be accomplished in triplicate