DOLE/BWC/OHSD/IP-6a
Republic of the Philippines
Department of Labor and Employment
REGIONAL OFFICE NO. .........
GOVERNMENT SAFETY ENGINEER’S ACCIDENT
INVESTIGATION REPORT
(This report shall be submitted to the Bureau of Working Conditions not later than the 30th day of
the month following the date of occurrence.)
1. Establishment Police Other (Name)
ORIGIN
2. Telephone Telegram Messenger: Other
(NOTICE)
Other______________
3. Establishment___________________Nature of Business__________________
4. Address________________________________________________________
EMPLOYER
5. Manager___________________________Nationality____________________
6. Employees & Workers: M___________F____________Total______________
7. Name____________________________Age_____Sex_____Civil Status_____
8. Address_____________________________________No. of Dependents____
INJURED
9. Occupation_________________________Average of Weekly Wage P_______
10. Length of service prior to accident__________Accident Record____________
11. Date of Accident_______________________________Time______________
12. This accident involved_______Personal Injury______Ptoperty Damage_____
13. Description of accident. (Give full details on how accident occurred):_______
______________________________________________________________
_____________________________________________________________
THE ACCIDENT
14. Activities performed before accident__________________________________
Was this part of regular job?________If not, why?_____________________
15. No. of similar accidents in the past 2 years____________________________
16. No. of injuries in the past 12 months_________________________________
Total__________Non-Disabling__________Disabling_________Fatal_______
17. Extent of Injury___________Fatal___________Permanent Total___________
18. Nature of Injury__________________________________________________
INJURY
19. Part of body affected______________________________________________
20. The Agency Involved______________________________________________
21. Part of Agency Involved___________________________________________
22. Unsafe mechanical or physical condition______________________________
CAUSE
23. Accident Type___________________________________________________
24. The Unsafe Act__________________________________________________
25. Contributing Factor_______________________________________________
26. Describe kind and extent of damage to equipment, materials, machinery and
PROPERTY
tools:__________________________________________________________
DAMAGE
______________________________________________________________
PREVENTIVE 27. Preventive measures taken:________________________________________
MEASURES ______________________________________________________________
28. Supervisor/Foreman (Name)________________________________________
WITNESS 29. Worker (Name)__________________________________________________
30. Others (Name)__________________________________________________
REMARKS 31. _____________________________________________________________
RECOMMENDATIONS _____________________________________________________________
Investigation conducted in the presence of: ________________________________________
___________________________________ Industrial Safety Engineer
(Name and Position) Date____________________________________
