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Government Safety Engineer's Accident Investigation report
BWC investigation report form for government safety engineer's accident
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Regional Office No. ______
GOVERNMENT SAFETY ENGINEER’S ACCIDENT
INVESTIGATION REPORT
(This form shall be submitted to the Bureau of Working Conditions not later than the 30 th day of the month following the date of
occurrence)
ORIGINAL
(NOTICE)
1.
2.
Establishment
Telephone
Police
Telegram
Others (Name)
Messenger
Others : ______________
3. Establishment:_______________________________________________________
Nature of Business:___________________________________________________
EMPLOYER 4. Address:____________________________________________________________
5. Manager:____________________________________________________________
6. Employees & Workers:
M
F
Total
7.
INJURED 8.
9.
10.
Name:___________________________
Age:___ Sex: __ Civil Status: _____
Address:________________________________________________
No. of Dependents :_____
Occupation: __________________________
Average Weekly Wages: _________
Length of Service prior to Accident : _______________ Accident Record: ______________
11. Date of Accident: ___________________
Time: _______________
12. This Accident Involved :
Personal Injury
Property Damage
13. Description of Accident: (Give full details on how accident occurred): ___________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
14. Activities Performed Before Accident : _____________________________________________
Was this part of regular job? ____
If not why?: __________________________________
15. No. of similar accident in the past 2 years: __________________________________________
16. No. of injuries in the past 12 months: ______________________________________________
Total _____________ Non-Disabling______________ Disabling _________ Fatal _______
INJURY
CAUSE
17. Extent of Injury: ________Fatal ___________ Permanent Total _________________________
18. Nature of Injury: ________________________________________________________________
19. Part of body affected : ___________________________________________________________
20.
21.
22.
23.
24.
25.
The Agency Involved: ___________________________________________________________
Part of Agency Involved: _________________________________________________________
Unsafe mechanical or physical condition: __________________________________________
Accident Type: _________________________________________________________________
The Unsafe Act _________________________________________________________________
Contributing Factor _____________________________________________________________
26. Describe kind and extent of damage to equipment, materials, machinery and tools : _____
_________________________________________________________________________________
__________________________________________________________________________________
PREVENTIVE 27. Preventive measures taken: __________________________________________________________
MEASURES
__________________________________________________________________________________
28. Supervisor/Foreman (Name) : ________________________________________________________
WITNESS 29. Worker (Name) : ___________________________________________________________________
30. Others (Name) _____________________________________________________________________
__________________________________________________________________________________
___________________________________________________________________________________
REMARKS/RECOMMENDATIONS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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____________________________________________________________________________________________
Date: _______________________
Investigation in the presence of:
Safety Engineer/s:
________________________________________________
(Signature Over Printed Name and Position)
______________________________________________
(Signature Over Printed Name and Position)
