OSH Form DOLE
OSH Form DOLE
OSH Form DOLE
• Description of services:
___________________________________________________________________
___________________________________________________________________
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Basic Components of Company OSH Program and Policy
(DO 198-18, Chapter IV, Section 12)
*(Applicable for medium to high risk establishments with 10 to 50 workers and low to high
risk establishments with 51 workers and above)
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1.0 Company Commitment to Comply with OSH Policy
to comply with the requirements of RA 11058 and DOLE Department Order 198-18 (its
Implementing Rules and Regulations) and the applicable provisions of the Occupational
for implementing this OSH program including orientation and training of its employees on
OSH, provision and dissemination of IEC materials on safety and health, provision of
Personal Protective Equipment (PPE) when necessary and other OSH related requirements
and activities, to ensure the protection for our workers and employees against injuries,
illnesses and death through safe and healthy working conditions and environment.
as comply with other provisions of this OSH program. That we are also fully aware of the
penalties and sanctions for OSH violations as provided for in RA 11058 and its
________________________________
ELGIN L. QUE
General Manager
February 16, 2024
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2.0 General Safety and Health Programs
21. Conduct of Risk Assessment
Kindly accomplish. Pls use additional pages if needed. You may also wish to attach your
Company’s Risk Assessment Matrix as substitute
• How may treatment rooms/first aid rooms are existing in your company? ______
• How many Clinics in the workplace? _______
• What hospital (s) are you affiliated with? _______
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3.0 And 4.0 - Health Programs for the promotion, prevention and control
The SHC of the company is responsible to plan, develop and implement OSH policies
and programs , monitor and evaluate OSH programs and investigate all aspect of the work
pertaining to the safety and health of all the workers. SHC shall be composed of the
following in compliance with the law:
(a) For establishments with less than ten workers and low risk establishments with
ten (10) to fifty (50) workers. – A SO1 shall establish an OSH committee composed of the
following:
Chairperson : __________________________________________________
Name of Company owner or manager
Secretary : _________________________________________________
Safety officer of the workplace
__________________________________________________
Member : Name of at least one (1) worker, preferably a
union member, if organized
(b) For medium to high risk establishments with ten (10) to fifty (50) workers and low
to high risk establishments with fifty-one (51) workers and above. – The OSH committee of
the covered workplace shall be composed of the following:
Ex-officio : _______________________________________________
chairperson Name of Employer or his/her representative
Secretary : ________________________________________________
Name of Safety officer of the workplace
Ex-officio :
members ________________________________________________
Name of Certified first-aider/s
_________________________________________________
Name of OH nurse
_________________________________________________
Name of OH dentist, and OH physician, as applicable
__________________________________________________
Members : Name of Safety officers representing the contractor or
subcontractor, as the case may be,
___________________________________________________
Name of workers’ representatives who shall come from the
union, if the workers are organized, or elected workers through
a simple vote of majority, if they an unorganized.
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(c) Joint Coordinating Committee: For two (2) or more establishments housed
under one building or complex including malls.
Chairperson : ________________________________________________
Name of Building owner or his/her representative such as the
building administrator
Secretary : _________________________________________________
Name of Safety officer appointed by the Chairperson
Members : __________________________________________________
__________________________________________________
__________________________________________________
Name of two (2) workers’ representatives one from which must
be from a union if organized from any establishments under
the building
(All members of the HSC shall perform their duties and responsibilities by the OSH law
and its implementing guidelines.)
Safety and Health Committee Minutes/Reports submitted to DOLE (pls attach latest OSH
committee minutes/report)
List of competent emergency health personnel within the worksite duly complemented by
adequate medical supplies, equipment and facilities based on the total number of workers.
(Use additional sheet if necessary and attach all required training certificates in this section.)
Emergency Health Personnel and Facilities
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Total number of Health Personnel & Facilities
Shift/Area/unit/ workers/area Health Personnel (First- Facilities
Department aider, Nurse, Physician, (Treatment Room/
Dentist) Clinic/ Hospital)
7.0 Safety and Health Promotion, training and education provided to workers
Any dangerous occurrence, major accident resulting to death or permanent total disability,
shall be reported by the company to the DOLE Regional Office within twenty four (24) hours
from occurrence using the prescribed form (Work Accident / Incident Notification).
After the conduct of investigation, the company shall prepare and submit work accident
report using the prescribed form (WAIR). Moreover, other work accidents resulting to
disabling injuries such as Permanent Partial Disability and Temporary Total Disability shall
be reported to the DOLE Regional Office within 30 days after the date of occurrence of
accident using the DOLE prescribed form (WAIR).
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All near misses shall be recorded and reported. A system for notification and reporting of
work accidents including near misses within the company shall be developed and reviewed
by the OSH Committee as necessary.
(Kindly submit reports on the following: Work Accident /Injury Report (WAIR), Annual
Exposure Data Report (AEDR), Annual Medical Report (AMR)
Report Submitted Date
Kindly attach dust control procedures, plans on temporary structures, permits app;icable
for the operation of electrical, mechanical, communications systems and other
requirements
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19.0 * Cost of implementing company OSH program
*(Applicable for medium to high risk establishments with 10 to 50 workers and low to high
risk establishments with 51 workers and above)
Php _______ ; Annual estimated amount for OSH program implementation to include but not
limited to the following: orientation/training of workers, safety officer, OH personnel,
purchase and maintenance of PPE, first aid medicine and other medical supplies, safety
signages and devices, fire safety equipment/tools, safety of equipment ( i.e machine
guards,) etc.
PPEs
OSH trainings
Safety Signages
Medical examinations
Medical supplies/medicines
Others: Specify
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ANNEX A:
The company shall ensure that worker’s health is maintained through the following
company programs and activities:
a) Orientation and education of employees
b) Access to reliable information on illness and hazards at work
c) Referral to medical experts for diagnosis and management of illness or health-
related concerns
d) Provide health-related programs such proper nutrition and exercise activities are
made available to the workers
In addition, company policies to protect workers’ rights arising from illness shall be
guaranteed. The company shall promote the following workers’ rights:
a) Confidentiality of information
b) Non-discrimination including non-termination
c) Work accommodation following a course of illness
d) Assistance to compensation
______________________ ___________________________
Owner /Manager Employees’ Representative
DATE: ______________
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