DOLE/BWC/OHSD/IP-6

Republic of the Philippines

Department of Labor and Employment
BUREAU OF WORKING CONDITIONS
Manila

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 20th day of
the month following the date of the accident)
____________________________________________________________________________________________________________________________________
Bamberton Center
1. ESTABLISHMENT_________________________________________________________________________
2. Block 10 Lot 14 Arca South, Western Bicutan, Taguig City Metro manila
ADDRESS ________________________________________________________________________________
EMPLOYER 3. MaxBlocks Construction Corp.
NAME OF EMPLOYER___________________________NATURE Construction
OF BUSINESS_____________________
___________ 4. NUMBER OF EMPLOYEES: 212 6 218
MALE_______FEMALE_______TOTAL____________________________
INJURED 5. Rogelio Bartulay
NAME____________________AGE_____ 50 M
SEX ______ Married
CIVIL STATUS______________________________
OR 6. Maharlika Village, Taguig City
ADDRESS_________________________________________________________________________________
ILL PERSON 7. 4,200 pesos only
AVERAGE WEEKLY WAGE_________________________________________________________________
8. 2 years
LENGTH OF SERVICE PRIOR TO ACCIDENT OR ILLNESS______________________________________
9. Foreman
OCCUPATION____________________EXPERIENCE 12 years
AT OCCUPATION____________________________
___________ 10. 1st Shift
WORK SHIFT______1ST______2ND______3RD 8 hours
HOURS OF WORK/DAY_____WEEK________________ 48 hours
11. November 16, 2021
DATE OF ACCIDENT/ILLNESS__________________________________TIME_______________________ 4 PM
ACCIDENT 12. THE ACCIDENT INVOLVED PERSONAL INJURY_____________PROPERTY Minor Cut None
DAMAGE _____________
OR 13. DESCRIPTION OF ACCIDENT OR/ILLNESS GIVE FULL DETAILS ON HOW A CCIDENT/ILLNESS
ILLNESS While cutting of rebar at the fabrication area his finger caught in between by the cutting tool.
OCCURRED______________________________________________________________________________
14. WAS INJURED DOING REGULAR PART OF JOB AT THE TIME OF ACCIDENT OR ILLNESS?
Yes
IF NOT WHY? ________________________________________________________________________
NATURE AND15. EXTENT OF DISABILITY_____FATAL______PERMANENT TOTAL____PERMANENT PARTIAL_____
EXTENT OF TEMPORARY TOTAL_______MEDICAL TREATMENT______ Medical Treatment Case
Lacerated Wound
INJURY OR 16. NATURE OF INJURY OR ILLNESS_______________PART OF THE BODY AFFECTED_______________ Right Middle Finger
ILLNESS N/A
17. DATE DISABILITY BEGAN__________________DATE Same
RETURNED TO WORK_____________________day ( 11/16/2021)
N/A
___________ 18. DAYS LOST_____________________________OR DAYS CHARGE________________________________ N/A
N/A
CAUSE OF 19. HE AGENCY INVOLED____________________________________________________________________
N/A
ACCIDENT 20. THE AGENCY PART INVOLVED_____________________________________________________________
OR Medical Treatment Case
21. ACCIDENT TYPE___________________________________________________________________________
ILLNESS N/A
22. UNSAFE MECHANICAL OR PHYSICAL CONDITION__________________________________________
Improper positioning
23. UNSAFE ACT_____________________________________________________________________________
lack of training
____________ 24. CONTRIBUTING FACTOR__________________________________________________________________
Reorientation of the Employee / Training Conducted
25. PEVENTIVE MEASURES (TAKEN OR RECOMMENDED)________________________________________
PREVENTIVE26. MECHANICAL PERONAL PROTECTIVE EQUIPMENT AND OTHER SAFEGUARD__________________ YES
MEASURES 27. WERE ALL SAFE GUARD IN USE?___________IF YES N/A
NOT WHY?____________________________________
None
____________ 28. COMPENSATION _________________________________________________________________________
Taguig Pateros hospital
MANPOWER 29 & 30. MEDICAL & HOSPITALIZATION. . . ._____________________BURIAL N/A
_______________________
5 hours
31. TIME LOST ON DAY OF INJURY. . .HOURS____________________MINUTES______________________ N/A
N/A
32. TIME LOST ON SUBSEQUENT DAYS, HOURS_________________MINUTES_______________________ N/A
(LOST TREATMENT OR OTHER REASON)
___________ 33. TIME ON LIGHT WORK OR REDUCED OUTPUT-DAY___________ 3 days PERCENT OUTPUT_____________N/A
N/A
MACHINERY 34. DAMAGE OF MACHINERY AND TOOLS (DESCRIBED) ________________________________________
AND TOOLS 35. COST OF REPAIR OR REPLACEMENT. . . . . . . . . . . N/A
P_____________________________________
N/A
___________ 36. LOST OF PRODUCTION TIME_________________COST P_____________________________________
N/A
37. DAMAGE TO MATERIALS (DESCRIBED)____________________________________________________
N/A
MATERIALS 38. COST OF REPAIR OR REPLACEMENT.. . . . . . . . . . . P_________________________________________
39. LOST OF PRODUCTION TIME _______________COST N/A N/A
P ______________________________________
N/A
___________ 40. DAMAGE TO EQUIPMENT (DESCRIBED) ____________________________________________________
N/A
EQUIPMENT 41. COST OF REPAIR OR REPLACEMENT. . . . . . . . . . . . .. P________________________________________
N/A
42. LOST PRODUCTION ON TIME______________COST P______________________________________
___________________________________________________________________________________________________________
I HEREBY CERTIFY on my honor to the accuracy of the foregoing information
_____________________________________
DATE

_______________________________________ ________________________________
Investigating Officer & Position EMPLOYER