Departmental Quality iorm

PSD-GF 404.4
Revislonr 01
Effecrivity Dale 06-07-201 2

PUBLIC HEALTH AND SAFETY DEPARTMENT

@
SUBIC BAY
crroPor [rtr lrtfionrlt
OCCUPATIONAL HEALTH AND SAFETY DIVISION
BIdg. 280, Dewey Ave., Subic Bay Freeport Zone, Philippines 2222
Tel. (63-47) 252 4502 Fax (63-47) 252 4106

REPORI"I NG REQU I REMENTS

FORM DEADLINE FOR
REPORT REQUIRED
TO USE suEililsstoN

Work Accident/Occupational lnJury or lllness Report lor Fetal, 404 24 hours upon
Ferrnanent Tolal, Permananl Fartial, Temporary Total Disabiiities occurrsnce of accidant
ll

Work AccidenU0ccupational lnjury or lllnass Report for Medical 408 1Olh day of the monlh
Treatment lnjuries with or without
accident/illnets

Employer's Annual Report on $afety and ficcupatinnal Health 405 January ?0th
Fersonnel and $ervices

Employer's Annual Report of Work Accident/lllness Exposure 406 January Zo'h

Annua[ Modical Repofi 4fi7 January r}'n:

GENERAL INSTRUCTION$ ,
t. Forms 404 and 408 shall be used only for WORK-RELATED aocidents, lnjuries and illne$se$, For
the purpose of determining whether the accident/iniury/illness is work-related or not, the company
physir:ian and the safety officer shall be consulted. In the absence of both, the hlghest occupational
health ancf safetv personnel shall be con*uited'

2. Wurk accident/injuries/illnesses shallbe classified as folluws:

a. Medical Treatment lniury - an injury which cloes not result in a disabting injury but which requirBs
first aid medical treatment of any kind
b. Fatal Accidentllnjuryllllness * any doath resurlting from a work injury rBUardlBBE of the tirne
intervetring hetween injury and death
c. permanenl Tota{ Disahitity - any injury or $ickness other ihan death which permanntly and
totally incapacitates an employee from engaging in any gainful occupatlon or which rdsult$ in the
loss or the cornplete loss of use of any of lhe following in one accident
Both eyes
One eye and one hafld, dr arm, or leg or foot
Any two of the following not in the sanre linrb: hand, arrr, foot, leg
Perrnanent complete par*lysis of ths lwo limbs
.
Brain injury resultlng in incurahle imtreciltt] or insanity
d, Fermnnent Partiai ilisability *
any injury otlrer than death or permanent tstal dlsability which
results in the loss or loss of use of any menrber or part of a m'ernber of the body regardloes of
any pre-existing disability of the it'rjured menrher or impairbd body function,
e, Temporary'Total Disability any -
injury or illrtess which doss not result in death or permanent
total or permanent partial disabiliiy but which results in disabitily fram work for a day or mor.
 Departmenlal Qrr3lity Fornr t
trSD QF 404-3 rage 1 ol 2
Revis.ion: 01
E'fec!.v ry Da:e. 46.07-20'2

PUBLIG HEALTFI AND SAFETY DEPARTMENT

S
@UBIC BAY
Efi1]m-ln-nfifii?ii;
OCCUPATIONAL HEALTH AND SAFETY DIVISION
Bldg. 280, Dewey Ave,, Subic Bay Freeport Zone, Philippines2222
Iel. (63-47) 252 4502 Fax (63-47) 252 4106

WORK ACCIOEI{TIOCCUFATIONAL INJURY OR ILLNE$S REPORT

{FATAL, FERMAHENT TOTAI, pERMANENT FARTTAL, TETHPORARY TOTAL DISABILITIES} :
This report shall be subrnitted by the employar Ior avery acddenl or lJlnesg
to lhe $BlllA Occupallonsl Haaith and Safety Divisiorr within 24 hours lollowing tha date of occurTence

Establishment:
Address. Nature of Buslness:
EMPLOYER Name of Employer: Nationality:
Number of Employees Male: Female:

Name: Age: Sex: _ Civil Status: .---*

INJURED OR ILL AddTESS:
PERSON Avarage Weekly Wagel No. of Dependents:
Length of service prior to accident or illness:

rr/Ar.lnn.rrr\hrAr owupirltof!: **- Experience aiOccupalion;

HISTORY Work Shift; tr 1st tl 2nd tr 3rd Hrs ofwork/day: DayAtVk:

Date of occurrence: Time: Location:

. TypB of accident: E personal injury tr proporty damage
Description of accident/itlness (Give fulldetails on how accidsnUillnoss
ACCIDENT occurred):
OR
TLLNESS

Was injured doing reguiar part of iob at the tlme of accidenUillnes$? trY tlN
lf no" why?

Extent of disabiritv partiar

NAT,RE AND H ff#;[1]-,:111 E ffiil'n-nt
OF
EXTENT Nature of iniurylillnessl
OR
INJURY BodY Pari affected: lf involving uppsr limb, handedness:
ILLNESS Date disabilitY begun: Date returned to worls:
Days lost:

The agency involvedr

on *:Y-"i:If;
[Iil'##'' "^ llsale
nccrpEr.rr
Accident t
condition;
Llchanical/physicar
The unsafe act:
Contributing factor:
 ilrrrillnrenlEl (,luality f-orni
PSD,0l 4l,i"B Page 2 'ri 2
Rev sior; 01
Efiectivily Dale 06-07-2012

Prevontive rfleftsurss {taken or resommended);

FREVENTIVE
MHASURES pr0vided:
Were all $afsguards in use? trY tlN lf no, why?

nnmnattsationl I
MgO;ca: ijr ru rru.-J*---r:
Burial:
MANPO\'VER
Tirne lost on dy of iniurv urs: Mins: I

Tirle lost fln sllhsequent days Hrs: [4ins:

Tinre on JJg!-rl i,vork or redL;ced oltiput Try-'* Percenlillflut:

t"-
Damage to machinery and tools (describe):
(IJ
MACHINEHY
o
(J AND TffilLS f;nst *f r&pair or replacem*nt:
F Lost prnduction tir'ne: Costr
Z
ur
g
(.)
u Damnge iCI rnntenills {riescribei:
{
MATERIALS
Cost of repair or replacfirTlffnt;
Losi prodr"tction tlme: Cust:

Damage to equipntent (descrii:e):

EQUlFMENT
Cost of repair r:r replacentenl:
Losl production time: C0st:

Wu hereby cortify on Dur honor t* the Eci:Hracy and cornpletoness of the foregoing lnforrnallon'

lnvestigating Officer Signatur0l

Name:
Pcsitisn:

Empioyer $lgnature:
lriai'ne:
I
I
I

:.,
Daie :

:
 Depaiiins|rlai Cual ir FLYrr
PSD'0i: 405 Page 1 cf 2
Revison B1
Eflectivily Date 06,07-?ti1 2

ffih
PUBLIG I{EAI.TH AND SAFETY DEPARTMENT
W
E*r#J##*#
OCCUPATIONAL HEALTH AND $AFETY DIVI$ION
Bldg. 280, Dewey Ave., Subic Bay Freeport Zone, Philippine* 27?2
Tai" (63-47) 252 4542 Fax (63-47) 252 4146

EMPLOYE.R's ANNUAL HEPCIRT OH

SI\FETY AHD OCCUPATIOHAL HE.ALTI.I PERSONNEL AND SERVTCES
{'l'hi6 report shatt be subrritttsd by Ure amployer to ll're SBM.,{ Occupattonal Health and $alety Division
wiUrin 2B calendar days foliowing tlre end of each calandtsr year.)

Period Covered:

tiame of Hstalrlisirmenti
Adclress;

Nature af Business:

Perscr"rs E rrt pio yecl, inclurJing rn a n agei'n e nt:

lST.SHIFT TIME: Male: Female:
2Nt).$HIFT Tirne: Male: Female: ;.*-:
3Rt) SHIFT Tlme: Male: Female;

SAFETY AI\ID HEALTH COMMITTEE

Type of Safety and Hehlth Cnmrnittee:

Con:position of Safeiy and Hrsalth Ccrrrrnilte*:

Chalrman: Pasltion in Establishment:
Mernbers: Position in EstablishmBnt:

Secretary: Fositiorr in Estab,ishrnorit:

Suhdule of Regular Meeting:

Objectives for tlre Curreril Year;
Reguler Activities:

SAFETY OFFISER
Name: F-T PT
lf part-titr:e. positinn in company: No" of hrs, deYoted to safetyfwk;
'I-rainirrg irr Safety:
; Date obtained:
 DBparlnef lal Qralriy rorn
irS)-QF ,il15 Page 2 ot 2
Revrs cr 01
EflBcllvity Date 01i-t7-2012

SAFETY. CONSULTANT

Name:
Accred itatio n/qualifi*ation :

COMPANY trHY$ICIAH I

Name: FT PT Clinlc Hours in ConrPanY:

PRC License #: FfulA #: PCOM #:
Training in Occupational Health: Dat6 obtainsd:

COMPANY DENTIST
l*lame: FT FIT CIinic l'"|$urs in ComPanY:
PRC Lisense #; I
Training in Occupat{onal l{ea}th: Date obtained:

SOMPANY NUF,sE

Ndme: F.:l' i:rT Working l{$urs {as co. nurse)l

trRC Lirense #: (Jl-1f.lAP 4^

Training in OccuPational Hoalth: Date obtained:

FIRST AINER

Name: T'raining: Date obtained:

Dr:cuments Attached/Encloseit ('/ ;:

Corrrpany adrtinistratil'e pniici*s on st*ftlty ano health

Occupational health Prsgrurn

[f isaster contlngenry pian iri*luciing enru.rgeflcy serv]r:e units established
:.*-: Sofety anei health training c*rrcJr.rctesl for l!-re rrast year and number of attendees
:: Sample rninutes of safely and heinlth nr:rt:rrai{tu* rn*etirlg
_ Sarrrple workplace safetlr arrd lrealth insl;+:cticirt fepc'lt
$arnple accldent investigation repart

I horeby cerrlfy on my honor to the accuracy and cornpletsness of thE foregolng lnfermatlon.
I

General Manager/Em PloYor

Date:

t
 Dep;,tml,ia Qlai iY Fr:"m

[:;',,ti.;ii'
Eile'itiv b/ Daier 0rj-07-2ii12

OCCUPATTONAL F{EALTH AND SAFHTY BIVISION

PUBLIC !4E,Ai.TI-! ANB SAFETY
Biclg.2B0Derr,evAver,ue.$ub'ioBayFreeportli:rre,lshllippines2-v'?-2
e 1O+21 252-4502 trax no' (047) 252-4106

EMPL.oYER'S ANNUAL REFORT OF WORK ACCIDHfr{T'ILL}*TE$S EXtrDSURE

report shall tre suhrnltted by ltre emptoyer tn ttre SRMA Occupatlonal )'lealth $nd Safsty Flvltlon
{Thts
wiihin I0 caleridar clays foliowirrg tlre errd of ea*h calendar year"I f

Period Ccrvered:

hlame r:f {istabiishment:

r

Addrelss.
Nat,ure of Business:

EXPOSUfIE DATA
-i-otal truntbe;'of emplriye*$; durins the yearl
r
Totai hours work*rJ by ail t:!Yjp;cly$t:s durirg the yeari i,

INJURY SUMMARY
Total nurnber af dtsabiing iniuries/illnesses:
Total number of nnn-disabling injuries/illnesses:
Tolal nurnber of days of clis,,ibiiil.y due 1o ierr:purnry iotal injuries/illnessos:
Totai nurnbef of clays charged to fatal, prlrnrarnerri total
and permianent partlal iniuries/lllnesses:

Frequenc-"* rale: ,t
i:

Severily rate:

of the foragolttg lnformation' l

I heraby certify on my trono, ta the accuracy and completdncsB

:

General Manager/EmPloYer
Daie:

drrring the pqrlod r;ovFred'

1- This raport shall be accontpllsh#d 'r.rhetlrr*r ur not there"Trere ecciclerlulllnesr} Gc[ur]eno$c
hours rrl expc'jsurG"
Frequency rate is the-toial numb{lr- <:f disall:lir'rg irrjr.rrlus per ritiliiorr errrployee
Ns:r1:Lrcr o{ tllsabiiiig in!ur{es x 1'OrlO'OOO
FreqrencY rate *
Errrpkj:r'eE-h$urrs of oxPosure
I

hours of expost'rfe'
Severity rate is the tstal numbsr of days losl or chars*d per nrillion employee
,I

I
3.
N*nri:trr nl r1;r3,:+ c;f rjlsabllttv arrd nuirtbor of days charged x 1|OOO'O0O

SeverllY rate =
Eryrployee-a luurs o1' *txtrrdl$;u te
ir-i{rit'j(1in(J r}rfii}loY?es (]9 opslst{ng DrDductlqn'
4, Exl:osrrre iri tha tcitai rtunrSer $f hours rr;rirkeri by ail erlrlrigyseii
prtJ olhel dspartrnerlts"
6raintenance. tn*nrporfttiori. it*ricsi ;:r:jrnir:isltratiu6, $61lss
tstdl djsahllity, D*r'nanBnt partial dlsabllliy or
Disabllng tnjuries are wcrk jrriui"ies vlhicr, resurt im deatil" Ferfili)nent
teurporaiY tolsl disafrtlity,
\A4rich cri not resLrlt lrrtc clitai:ll*g lrrjurles bLrt
rBqulrG flrst sid or
6" Non-rjlgabling in.]uries (rnadical 1reHt!'icrili.) are irtiurtes
meciical Etlentlon of anY kind'

;
 lriPartmeniij lilai1Y l-:rrrr

P$D-IF 437 Pag 1 ci 6

teuision: 01
Effcl viiY Dater 06-C7-20 1 2

OGCUPATICINAL HEALTH ANT} SAFETY D IVIS IO N

PUBLIC HEA!.TH AND SAFETY
Bldg. 280 Dewey Avenue, Subic Bay Freeport Zone, Philippines 2222
8 {047) 252-4502 Fax no. (0471252'4146

ANNUAL MEDICAL REPORT

jItlMA Occupatlcnal Heaith #nd Safety Divislon
{Ttris raprrri shali hs subrrritled try tl,e *rnFrl$yrr 1ei tlr*
withi* !fi cal{indsr days followirril llre enrl rrf each nalendar year.)

Period CovereC:

Name a{ Establlsliment:

Address:

Name of Owner:
!
i

Nature nf Business: I

;l
Fers clns loye d, in clu d in g rfl anar:i' 6ril Brlt
E rrr p i

1ST SFIIFT Time: Male: Female:

zND SHIFT Tirne: Mm!e: Fernale;
3Rtr SHIFT Time; i'v4ale: Female:

Pre vontlvs Occupa fJonef f{eaJffi Services.'

i

a. Occupational health fiErvices is organizediprovided by (/): I

i
I

if
tr the establishment l:
t.
il government authority/instituiion I

U other bodies/grr:upsllnstituti*tr; Sp"recify.

b. Occupational health $ervices as doscribed atrove is orEanlzed/provlded aB a service:
t -*iclely far the wsi^kens Of the r+.*tmi.iiiShrnelt/unr:ieriaking
il common tc a nurnbsr *f e*tahtishrneritJundertakings
Specify other establishmtsrlt*:

c. -Ihe BrflplCIyer eng&ge$ {fits servifres afi

E 0ccuPational healtlr PhYsician
Name: Adcliess: Tel;
u Occupatifinal health dentist Tel:
Name: Address:
tl CJcr,r"rpatiunal heelth nur$ts
Tel:
i{anle; Address:
l

d. The gccupational health pnysirianldentis$rrur"se ccnCuctls an inspection of the

wsrkplflce: l,
I
t:
[]
once a rnonth [f
once in 2 rrt*riti'rs [J i:nce iri 3 months H once ln 6 nronths
lr
E others; Details: i

i
I

i'
I.
i..
I
 lleparinteNlal Qualrlv Fcrfll
PSD-AF 4t7 Pa$e 2 ci 6
;ie!isio'r: ,11

Erteci v tY Date: 06'07 201 2

Errergency Ocorrp ational l/raffft $*r'r'ices

a" -Ihe enlployer proL,idgs fi trei?tn"leiit rc:$rfi,'r1l*riiunl t.linlc in the r,vnrkplace with fiCf'IFLETE
nr*:dicirres anci facilities: [] Yes Ul F'lci

t). Schedul t:f attenr-lance in tht: workplar:e; Workshift:

()cct-tpirtional health physirian l''lo' of l"toL:rs/r1ay:
Occr:;leticnal heaith dentir;i Nr:- of hnursfulay': Workshift:
f)ccupatifi nal ltBaith ntir$e No" r:f hr:urs/Clr,ty: Wbrkshift:

c, Schedule nf altendance (Jr trrrr Li!',+ r:"a+ 'rie'rar"

fl first workshifl fi secfi,ncl wr:rk.shi{t ff ilr:rd workshift

ri" -I'ire occupationai heailir pe,'sottttel of lhis *statrlisl-rment have uridargone training
folio.,ryrng
irt
orci.rpatir:rraI health and strfety/first airJ:
fl occu'Srational heelth physician
Ei occuPatic.:nal trealfh cleniist
fl occt-rpational health nurFE
il f irst -aicler
t-l trthers I

Sccupaf i rt n a I H eaJtfr Scr-visers

a. The CIccupatisnal heelth persnnnel of ttlis establishrrient conrJufits regutar appraisal of tne
sanltatlon systern in the wr:rkplace' ff Yes Il Fio
b" hjurnber of workers who t,tfider"went tfle F{}}inv#itrr] :irerjica{ *xamlns}tions;
Pre-Pla+emnt Pericdic ITTW Trafisfer Speclal SeParation
Fhysical xal-r"
X-ray
Urinr:lysis
Stor,rl exam,
Bloocl test
0thers
t
ffeporf of Sisesses t.
I

dls*ases
i

a. [rJutrrbar <.:f consultationslirr:slmei:ts flor the. followirrE

lv4aitt Fernale .Total

5ikin
tl atlet'gY
ff derrrra'toses
n infection as f*llit':urlitis
m abscess/ParonYchia I

ff otirers l,
Heacl I

i
tl tension headache
tl others
HyEs
n Hrror rlf refraction
L] bacteria[/vlrai
n uorrir,rr:clivitis
H cataract
.il atlrers
t
!.
i
I
 Deparime,Ial Oual 1y Fcrnr
pSD"0F 40i i:age 3 rf 6
Rev sion 01
Effectivily Daler 06'07-201 2

l',4 i,t le Female iotai

Mouth arrd trNT
tl glrrgivitis
tl herpes iabialeslnasalis
Ll otitis rrredia/externa
n deafness
il nrnniere's'syndrom*/verligr:
n rrriniiislcnlds
tl narsal polyps
n si:rltsilis
U tonsillnpharyn$iti$
n Iat"yngitis
n ollrers
Respit'atory
[f trronchitis
f] brrorrchial as;lhrr.a
tl prreumnnia
m tLrbercuk":sis
tl pfterimDConiosis
il others
Hearl and Blood Vessel
fi hyperiension
n hypolension
fl arrgina pectoris
Ll nlyCIcardial infarctian
fJ vasclilar disturhance$ in
extren-rities clue to
contirruous vibration
lJ otrrers
GastrointestinaI
tf gastroenteritisidiarrhea
f: arnoebiasis
il gastriiis/hYPeracidltY
I} appendiciiis
fl infectious hePatitis
tl liver cirrhosis
n lrepatic abscess
n cancer (hepaticlgn*trir:)
il i:lcer
m r:ihers
Ger-,iio Urinary
tl *rinary tract infection
f] s-iones
tl c,rrrtcei-
n others
Reprodt.rctive
n dYsmenrirrhea
tl lnfection (cervicitis)
(vaginiti*)
A abortion (spnntaneCIils) -

(threatwned)
n lryperem esis gravidaritrm
trl uterine iumors
il cervical polyP/cancer
tr ovariaF cYsUtumors
 {leDarlmenlal Qualily Form
Psb-OF 407 Page 4 ol 6
Re!r$ion;01
Efiectivit Date 06-07'2012

Fomale Tstal
Mnle

tr sLd
m h*r:rla {inguirral}
(ferrr*ral)
tl otlrers oint*
ftfu *r" usc u larls keletali "l
il P*riPherat neuritis
tl tr:rlicoiitis
!J ai'll-rritis
L: ctlre rs,
LymPhatics an(l Cir*r-llatorY
lf arlen"]qa
fi lelrketnia
lf cereilrovatcLr[&r aficidsnts
fl iYrnPiradenitis
tf lYt'r:lrhomel
n ollrers
lnfecticus Diseases
tl influenea
t} tVPf:oiAfParatYPhr:id fever
-.-l!tdltt*r_-*,.A.,.Mdd

tl choiera
tl measies
il rnt"lll-rP$ '

[l tetarrus
fJ r:':alrlria
I] schistcsomiasls
tl
herPes uoster
If
clrtr:ken Pox
grnlan measles
5
n
railies @- .d-

tr
otlrers
TOTAI- NUMBER -.d-@f--tt.g.#

hr,Nunibercrfthefoliowingdisease*d*-et*phvgtcarienrlironrnent
Dr-r* to noise und vibratton
"f,- ;;;;;ess qnoise inducet:)
fl wl:lte tirrgers disease
m Lnuscuioskeletai disturbanct:r*
il fatigue
E oll"rers *r:?i&nialitlers
#- ;;'te:'n P'er*t'':re and humiditY
Hol lemPerafure
il heat strok'e$
il heat crarnPa
tr delrYdration
n heat exhaustian ,*F.,<*#

il nttrers
Cotd t*n"rPerature '@**rs4?q#

fl chithlain
D frost'nrte
n immersion foot
tl geireral hYPotherrnta
fl ciirers
 Departmenta QL.raliiy Forrrl
35D"QI 407 Pa$e 5 oi 6
il+visron:01
Effectivilv Date iitr 07-2112

Male Female Total

Due tq: pres$ure abrrprnralities
n decompi"essi*n sickness
air emr)olisrn
t:ends disease
[] i:arotrpuma
il hypoxin
n altitude sickness i

Due tu radiation
tl calaracts
il kerirtit[s I.
lJ burns j?

n raCiation-i'elatecl Gfftlc*r$
TCTAL NIJMBER

Repa rt.of Occupa tlonal .Acciden fsy'lniunes

Mate Female Total

Cuntusion. brulsss, hernatoma
Abrasions l,

Cuts, laceratir:ns, punctures

1,,
Concussion
Avulsion
Arnputation, loss of i:ody parts
Crushing injuries
SpinaI injuries
CraniaI injuries
Sprains
Di sk:cation s/fractu res
Burns

Immunization Program findicafe murrfi *r irmrntrnizedJ

Male Famale Total
il Teianus toxoid inJection
tr Tetanus antitoxin injection
t Tetanus globulin injeciisn
tr Hepatitia B vaccine
il Rabies vaccine
tr Others {spacify}

Keepr'ng of Medical Fectrrds of Workers tl

t:

fl done il not done

Healttt Educatipn nnd On*rmsellfng fuy Her/rll arr#.$afefy Personnel {c}reck ona or mare}

tl done individually as each wcrker fiomes to the clinic fr:'t ccnsujtation

[J Cone in organirmd group discussiCIns/semirer-s
tJ done with the use of rrisuai dieprlirys andlnr nrornntional rnaleriais, leafiets, etc.
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