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15-04 Monthly Employer's Report of Accident or Illness

MGB employer's report form for monthly accident or illness

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: MGB Form No. 15-4

Republic of the Philippines
Department of Environment and Natural Resources
MINE AND GEOSCIENCES BUREAU
North Avenue, Diliman, Quezon City

MONTHLY EMPLOYER’S REPORT OF ACCIDENT OR ILLNESS
EMPLOYER :
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Name of Operating Company ___________________________________________
Address ____________________________________________________________
Name of Mine ________________________________________________________
Location of Mine _____________________________________________________
No. of Employees : _________________ Male : ____________ Female: _________
Name _______________________________________________________________
Chapa No : ______ ____________________________________________________
Age: _________ Civil Status : _____________ No. of Dependents: ___________
Occupation when Injured : ___________ Experience at Occupation ______________
Work Shift ____ 1st ____ 2nd ____ 3rd Hrs. of Work/day :________ day/work
Average weekly wage : ___________________
Actual Duties at the Time of Accident : _____________________________________
Length of Service prior to Accident or Illness ____________

ACCIDENT OR ILLNESS
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Date of Accident/Illness : _____________________ Time : __________________
Location of Accident/Illness : ___________________________
Mining Method : _____________________ Beneficiation Process : ______________
Type of Accident :
Personal Injury
( )
Property Damage ( )
Detail description of Accident/Illness
Was the injured performing his regular job at the time of accident/illness :
________________ if not, why _________________________________________

NATURE, EXTENT AND TREATMENT OF INJURY OR ILLNESS
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Extent of Disability : _________ Fatal ___________ Permanent Total ____________
Permanent Partial ________ Temporary Total _______ Medical Treatment ________
Nature of Injury or illness _______________ Parts of Body Injured _______________
Date of disability started _________________ Date Returned to Work _____________
Days Lost _____________________ Days Charged __________________
Treatment ____________________________________________________________
By whom __________________________________

CAUSE OF ACCIDENT
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The Agency Involved ______________________________________
The Agency Part Involved __________________________________
Accident Type ___________________________________________
Unsafe Mechanical or Physical Condition ______________________
The unsafe act ____________________________________________
Other contributing factors ___________________________________

PREVENTIVE MEASURES
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Remediation (undertaken or recommended) : _______________________________

MGB Form No. 15-4

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Provision for Mechanical Guards; Personal Protective Equipment etc. are adequately
met _________________________________________________________________

RESPONSIBILITY
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Was the Injured Negligent : ______________
Was the Official or other Employees Responsible : _______________

MANPOWER
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Compensation : __________________ Amount : ___________________
Medical and Hospitalization : _____________________________________________
Burial : _____________________________
Time Lost on Day of injury ___________ hours ___________ mins. ____________
Time Lost on Subsequent Days due to treatment or follow ups ___________________
hours _____________________ mins. _____________________
Time on light work spent : ______________________ hrs. _________ mins.________

ACCIDENT COST
Machinery and Tools Damage
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Damage to Machinery and Tools (Describe) ________________________________
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Cost of Repair or Replacement : __________________________________________
Lost Production Time : _______________________ Cost : ___________________
Damage to Materials (Describe) __________________________________________
_____________________________________________________________________
Materials

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Damage to Materials (Describe) : _________________________________________
Cost of Repair or Replacement : __________________________________________
Lost Production Time : ________________________ Cost : ___________________
Damage to Equipment (Describe) : ________________________________________
Cost of Repair and Replacement : _________________________________________
Lost Production (downtime) : ____________________ Cost: ___________________

DATE OF INVESTIGATION: __________________________
DATE OF REPORT
: __________________________
I HEREBY CERTIFY THAT THE FOREGOING INFORMATION ARE TRUE
AND CORRECT TO THE BEST OF MY BELIEF.
_______________________
Date
_______________________
Investigating Officer

_________________________
Employer

NOTE: Copies to be sent to the Department of Labor and Employment and to the Mines and
Geosciences Bureau’s Regional Offices, copy furnished - MGB-Central Office, by the
operator/employers.
 
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