Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
EMPLOYER
INJURED
OR ILL
PERSON
OCCUPATIONAL
HISTORY
ACCIDENT
OR ILLNESS
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NATURE &
EXTENT OF
INJURY OR
ILLNESS
CAUSE OF
ACCIDENT
OR ILLNESS
PREVENTIVE
MEASURES
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Establishment: __________________________________
Address: ________Nature of Business: _______________
Name of Employer: __________Nationality: __________
No. of Employees: ___M: ___ F: ___Total: ____________
Name: __________Age: ____ Sex: ____Civil status: _____
Address: ________________________________________
Ave. Weekly wage: P ____ No. of dependents: __________
Length of service prior to accident or illness: ____________
Occupation: _______ Experience at occupation: _________
Work shift: ___1st ___2nd ___3rd ___Hours of work/day:___
Date of accident/ illness: ______________ Time: ________
The accident involved: _________ Personal Injury: ______
Property damage: _______________
Description of accident/ illness( give full details on how accidents /
illness occurred):__________________________________
________________________________________________
Was injured doing regular part of job at the time of accident
or illness: If not, Why? ___________
Extent of disability: _____fatal: ___permanent total: _____
permanent partial: _temporary total: ___med. treatment: __
Nature of injury or illness: ____ parts of body affected: ___
Date disability begun: ____ Date returned to work: ______
Days lost: __________ or days charged: _______________
The agency involved: _____________________________
The agency part involved: ___________________________
Accident type: ___________________________________
Unsafe mechanical or physical condition: ______________
The unsafe act : __________________________________
Contributing factor: _______________________________
Preventive measure (taken or recommended): ____________
Mechanical guards, personal protective equipment and other
safeguards provided: ________________________________
Batangas Business Office: BS-01 Dimatatac Road, San Pascual, Batangas, 2404, Philippines
Tel. No.: (043) 727-1026 / 727- 4926 / Tele-Fax No.: (043) 727-1964
Email Add: m4cmsi@yahoo.com / Website: www.m-4constructio.com
27.
MANPOWER 29.
MACHINERY
& TOOLS
MATERIALS
EQUIPMENT
______________________
Employer
Batangas Business Office: BS-01 Dimatatac Road, San Pascual, Batangas, 2404, Philippines
Tel. No.: (043) 727-1026 / 727- 4926 / Tele-Fax No.: (043) 727-1964
Email Add: m4cmsi@yahoo.com / Website: www.m-4constructio.com