DOLE/BWC/OHSD/IP-6a

Republic of the Philippines

Department of Labor and Employment
REGIONAL OFFICE NO. .........

GOVERNMENT SAFETY ENGINEER’S ACCIDENT

INVESTIGATION REPORT
(This report shall be submitted to the Bureau of Working Conditions not later than the 30th day of
the month following the date of occurrence.)
1.  Establishment  Police  Other (Name)
ORIGIN
2.  Telephone  Telegram  Messenger: Other
(NOTICE)
Other______________

3. Establishment___________________Nature of Business__________________
4. Address________________________________________________________
EMPLOYER
5. Manager___________________________Nationality____________________
6. Employees & Workers: M___________F____________Total______________

7. Name____________________________Age_____Sex_____Civil Status_____
8. Address_____________________________________No. of Dependents____
INJURED
9. Occupation_________________________Average of Weekly Wage P_______
10. Length of service prior to accident__________Accident Record____________

11. Date of Accident_______________________________Time______________

12. This accident involved_______Personal Injury______Ptoperty Damage_____
13. Description of accident. (Give full details on how accident occurred):_______
______________________________________________________________
_____________________________________________________________
THE ACCIDENT
14. Activities performed before accident__________________________________
Was this part of regular job?________If not, why?_____________________
15. No. of similar accidents in the past 2 years____________________________
16. No. of injuries in the past 12 months_________________________________
Total__________Non-Disabling__________Disabling_________Fatal_______

17. Extent of Injury___________Fatal___________Permanent Total___________

18. Nature of Injury__________________________________________________
INJURY
19. Part of body affected______________________________________________

20. The Agency Involved______________________________________________

21. Part of Agency Involved___________________________________________
22. Unsafe mechanical or physical condition______________________________
CAUSE
23. Accident Type___________________________________________________
24. The Unsafe Act__________________________________________________
25. Contributing Factor_______________________________________________

26. Describe kind and extent of damage to equipment, materials, machinery and
PROPERTY
tools:__________________________________________________________
DAMAGE
______________________________________________________________

PREVENTIVE 27. Preventive measures taken:________________________________________

MEASURES ______________________________________________________________

28. Supervisor/Foreman (Name)________________________________________

WITNESS 29. Worker (Name)__________________________________________________
30. Others (Name)__________________________________________________

REMARKS 31. _____________________________________________________________

RECOMMENDATIONS _____________________________________________________________

Investigation conducted in the presence of: ________________________________________

___________________________________ Industrial Safety Engineer
(Name and Position) Date____________________________________