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Dole BQF Wair

This document contains forms for employers to report workplace COVID-19 prevention measures and work-related accidents/injuries to the Philippine Department of Labor and Employment. It includes sections for company profile information, details of COVID-19 screening of workers and clients, and details of occupational safety and health issues like the nature of accidents, injuries sustained, and corrective actions. Employers must submit this report monthly to provide updates on COVID-19 compliance and within 30 days of any notifiable accident or injury.

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beng acosta
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1K views

Dole BQF Wair

This document contains forms for employers to report workplace COVID-19 prevention measures and work-related accidents/injuries to the Philippine Department of Labor and Employment. It includes sections for company profile information, details of COVID-19 screening of workers and clients, and details of occupational safety and health issues like the nature of accidents, injuries sustained, and corrective actions. Employers must submit this report monthly to provide updates on COVID-19 compliance and within 30 days of any notifiable accident or injury.

Uploaded by

beng acosta
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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DOLE-BQF-WAIR

REPUBLIC OF THE PHILIPPINES


DEPARTMENT OF LABOR AND EMPLOYMENT
Regional Office No. _____

Workplace COVID-19 Prevention and Control Compliance Report


To be submitted every 30th of the month

(Mark with an X the appropriate box) WAIR COVID-19


Period Covered by Report (Month / Year)
Does the company have a policy on workplace COVID-19 prevention and control? Yes No
Is the policy communicated to all workers and clients? Yes No
Section I. Company Profile to be filled in by Employer or Representative (as indicated in the business permit)
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 COVID-19 Prevention and Control
Worker Details: Screened: Denied Entry: Referred:
Guest / Client Details: Screened: Denied Entry: Referred:
BHERT Health Facility (specify)
Where were workers referred?
Others (specify)
Did the establishment perform an optional diagnostic test prior to return to work of workers?
Yes No. Please proceed to signature
If yes, what? RT-PCR j RDT k Both l How many tests were done?
Details of Workers with positive results Total cost for the reported month:
Test Done Name of worker Birth Date Sex Occupation Home Address City Province
j k l
j k l
j k l
j k l
Attach additional pages as needed

We hereby certify that the information above is accurate to the best of our knowledge. We understand that
data contained herein is compliant to RA 11469 Bayanihan to Heal as One Act and protected by RA 10173
Data Privacy Act of 2012.

OH Personnel / Safety Officer Employer / Representative


Signature beside printed name Signature beside printed name

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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):

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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:

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DOLE-BQF-WAIR

Republic of the Philippines


Department of Labor and Employment
Regional Office _____

Work Accident / Injury Report Patients' Data Page


For multiple worker involvement. Insert additional rows or pages as necessary.
Page 1 of 2 WAIR-B
To be attached to WAIR-A.
Length of Length of Stay Work Work
Date of Accident:
Average Weekly Service in at Current hours Days
What is the
Employment wage Establishment current work Work per per
Name of Injured Worker Age Sex Occupation Status Philippine Peso In years assigned: Years Months Day Week
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We hereby certify that the information above is accurate to the best of our knowledge. We understand that this document is covered by the Data Privacy of 2012 and
that the Data Protection Officer or Data Privacy Manual was consulted on how to record, store and dispose this form.

OH Personnel / Safety Officer Employer / Representative


Signature beside printed name Signature beside printed name

1
DOLE-BQF-WAIR

Republic of the Philippines


Department of Labor and Employment
Regional Office _____

Work Accident / Injury Report Patients' Data Page


For multiple worker involvement. Insert additional rows or pages as necessary. WAIR-B
Page 2 of 2
To be attached to WAIR-A
Date of Accident:
Hospitalization Lost Work Return to
Saturday, January 00, 1900 Cost Days to Accident Type Body part/s and side Extent of Work
Name of Injured Worker Philippine Pesos injury ILO, 1996 affected Disability Date
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We hereby certify that the information above is accurate to the best of our knowledge. We understand that this document is covered by the Data Privacy of
2012 and that the Data Protection Officer or Data Privacy Manual was consulted on how to record, store and dispose this form.

OH Personnel / Safety Officer Employer / Representative


Signature beside printed name Signature beside printed name

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