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    Wair A

    Uploaded by

    Jan Lenon Guira
    This document is a Work Accident/Injury Report form containing details of a workplace accident. It collects information about the company, location and circumstances of the accident, health and safety hazards involved, injured worker details, costs of the accident, and certification by occupational health and employer representatives. The form will be submitted to the Department of Labor and Employment within 30 days of the accident.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Wair A

    Uploaded by

    Jan Lenon Guira
    379 views2 pages
    This document is a Work Accident/Injury Report form containing details of a workplace accident. It collects information about the company, location and circumstances of the accident, health and safety hazards involved, injured worker details, costs of the accident, and certification by occupational health and employer representatives. The form will be submitted to the Department of Labor and Employment within 30 days of the accident.

    Original Description:

    a

    Original Title

    WAIR A

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    This document is a Work Accident/Injury Report form containing details of a workplace accident. It collects information about the company, location and circumstances of the accident, health and safety hazards involved, injured worker details, costs of the accident, and certification by occupational health and employer representatives. The form will be submitted to the Department of Labor and Employment within 30 days of the accident.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    379 views2 pages

    Wair A

    Uploaded by

    Jan Lenon Guira
    This document is a Work Accident/Injury Report form containing details of a workplace accident. It collects information about the company, location and circumstances of the accident, health and safety hazards involved, injured worker details, costs of the accident, and certification by occupational health and employer representatives. The form will be submitted to the Department of Labor and Employment within 30 days of the accident.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    DOLE-BQF-WAIR

    REPUBLIC OF THE PHILIPPINES


    DEPARTMENT OF LABOR AND EMPLOYMENT
    Regional Office No. _____

    WORK ACCIDENT / INJURY REPORT


    To be submitted for every notifiable accident or injury to the DOLE Regional Office
    within 30 days after the date of the accident
    (Mark with an X the appropriate box) WAIR-A

    Did the accident have fatalities / Permanent Total Disability? Yes No


    Are there Dangerous Occurences: Yes, Type: No
    Was DOLE notified within 24 hours after the accident (DOLE-BQF-ALERT)? Yes No
    Was a work stoppage issued by the safety officer for this accident? Yes No
    Location of accident: Within Establishment Going to and from work In company vehicle
    At deployment site On official business trip (with office orders) In company sponsored event
    Section I. Company Profile to be filled in by Employer or Representative
    Establishment Name:
    Address of Establishment:
    Name of Business employing the worker:
    Nature of Business: Business Representative:
    Number of Workers: Male Female Total
    Section II. Details of Accident to be filled in by OSH Personnel
    Date of accident: YYYY-MMM-DD Time: 00:00 AM/PM Accident type:
    Safety Hazard (Choose all that apply): Unsafe Act Unsafe Condition Both
    Describe selected Safety Hazard/s:

    Health Hazard (Choose all that apply): Physical Chemical Biological Ergonomic None
    Describe selected Health Hazard/s:

    Other factors that may have aggravated the accident:

    Equipment / Materials involved in the Accident:


    Shift Schedule on the day of Accident: From: AM PM To: AM PM
    Events leading to the accident (You may use another sheet if more space is needed, attach pictures if available)

    Printed Name of Injured Worker or Representative Sign above your name if you agree to the events narrated
    Immediate Action done for the injured worker/s:
    Corrective Measures planned and expected date of implementation to prevent recurrence of accident
    (You may use another sheet if more space is needed, attach pictures if available):

    1 of 2
    DOLE-BQF-WAIR

    Section III. Details of injured worker (skip section if more than 1 injured, use WAIR-B instead) o WAIR B used
    Name of injured worker: Age: Sex:
    Worker Address: Employment Status:
    Average Weekly Wage: Length of service in Establishment:
    Current work: Work hours/day: Work day/week:
    Amount of time spent at current work: Years: Months: Days:
    Body Part/s affected (indicate if left or right):
    Extent of Disability: Permanent Total Permanent Partial Temporary Total
    Hospitalization cost: Lost work days due to injury:
    Return to work date: Nature of Injury:
    Section IV. Cost of Accident
    Approximate Cost to Operations (include cost of halting of production and cost to resume activities):
    Less than Php 5,000 30,001 to 100,000 500,001 to 1,000,000
    5,001 to 30,000 100,001 to 500,000 More than 1,000,000
    Was there any damage to properties, materials or machinery? Yes No
    Approximate Total Cost of Accident (Include expenses from Hospitalization, Cost to Operations,
    Machinery repair and replacement, Compensation, Penalties, and Burial):
    Less than Php 5,000 30,001 to 100,000 500,001 to 1,000,000
    5,001 to 30,000 100,001 to 500,000 More than 1,000,000

    We hereby certify that the information above is accurate to the best of our knowledge. We understand that the
    OSH Standards states that these report shall not be admissible as evidence in any action or judicial proceedings
    in respect to such injury, fitness or death on account of which report is made and shall not be made public or
    subject to public inspection except for prosecution for violations under this Rule.

    OH Personnel / Safety Officer Employer / Representative


    Signature beside printed name Signature beside printed name

    Date of Accident Investigation:

    2 of 2

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