The document is an employer's work accident and illness report issued by the Department of Labor and Employment in the Philippines. It requires employers to provide detailed information about any workplace accidents or illnesses, including employee details, nature of the incident, and preventive measures taken. The report must be submitted by the 20th day of the month following the incident.

1. 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)
1. ESTABLISHMENT : SUNFLARE INDUSTRIAL SUPPLY CORPORATION
2. ADDRESS: GOLDEN SUN 999 INDUSTRIAL PARK SAN PABLO LIBUTAD , SAN SIMON ,PAMPANGA
EMPLOYER 3. NAME OF EMPLOYER NATURE OF BUSINESS
4. NUMBER OF EMPLOYEES: MALE FEMALE TOTAL
INJURED 5. NAME AGE SEX CIVIL STATUS
OR 6. ADDRESS
ILL PERSON 7. AVERAGE WEEKLY WAGE:
8. LENGTH OF SERVICE PRIOR TO ACCIDENT OR ILLNESS
9. OCCUPATION EXPERIENCE AT OCCUPATION
10. WORK SHIFT 1ST 2ND 3RD HOURS OF WORK/DAY WEEK
11. DATE OF ACCIDENT/ILLNESS TIME
ACCIDENT 12. THE ACCIDENT INVOLVED PERSONAL INJURY: N/A PROPERTY DAMAGE: N/A
OR 13. DESCRIPTION OF ACCIDENT OR/ILLNESS GIVE FULL DETAILS ON HOW A CCIDENT/ILLNESS
ILLNESS OCCURRED: N/A
14. WAS INJURED DOING REGULAR PART OF JOB AT THE TIME OF ACCIDENT OR ILLNESS?
IF NOT WHY? N/A
NATURE AND15. EXTENT OF DISABILITY: N/A FATAL: N/A PERMANENT TOTAL: N/A PERMANENT PARTIAL: N/A
EXTENT OF TEMPORARY TOTAL MEDICAL TREATMENT
INJURY OR 16. NATURE OF INJURY OR ILLNESS PART OF THE BODY AFFECTED
ILLNESS 17. DATE DISABILITY BEGAN DATE RETURNED TO WORK
18. DAYS LOST OR DAYS CHARGE
CAUSE OF 19. HE AGENCY INVOLED
ACCIDENT 20. THE AGENCY PART INVOLVED
OR 21. ACCIDENT TYPE
ILLNESS 22. UNSAFE MECHANICAL OR PHYSICAL CONDITION
23. UNSAFE ACT
24. CONTRIBUTING FACTOR
25. PEVENTIVE MEASURES (TAKEN OR RECOMMENDED)
PREVENTIVE26. MECHANICAL PERONAL PROTECTIVE EQUIPMENT AND OTHER SAFEGUARD
MEASURES 27. WERE ALL SAFE GUARD IN USE? IF NOT WHY?
28. COMPENSATION
MANPOWER 29 & 30. MEDICAL & HOSPITALIZATION. BURIAL
31. TIME LOST ON DAY OF INJURY. HOURS MINUTES
32. TIME LOST ON SUBSEQUENT DAYS, HOURS MINUTES
(LOST TREATMENT OR OTHER REASON)
33. TIME ON LIGHT WORK OR REDUCED OUTPUT-DAY PERCENT OUTPUT
MACHINERY34. DAMAGE OF MACHINERY AND TOOLS (DESCRIBED)
AND TOOLS 35. COST OF REPAIR OR REPLACEMENT. . . . . . . . . . . P
36. LOST OF PRODUCTION TIME COST P
37. DAMAGE TO MATERIALS (DESCRIBED)
MATERIALS 38. COST OF REPAIR OR REPLACEMENT...........................P
39. LOST OF PRODUCTION TIME COST P
40. DAMAGE TO EQUIPMENT (DESCRIBED)
EQUIPMENT 41. COST OF REPAIR OR REPLACEMENT..............................P
42. LOST PRODUCTION ON TIME COST P
I HEREBY CERTIFY on my honor to the accuracy of the foregoing information
DATE
Engr. Kent Darryl Rodriguez
SAFETY OFFICER EMPLOYER