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15-5 Monthly General Accident Report
MGB report form for monthly general accident
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: MGB Form No. 15-5
Republic of the Philippines
Department of Environment and Natural Resources
MINES AND GEOSCIENCES BUREAU
North Avenue, Diliman, Quezon City
MONTHLY GENERAL ACCIDENT REPORT FOR ___________ , 19 ___
During the month of ____________ , 19__, there was a total of ________ Industrial Accident cases.
The following is an analysis of these accidents :
1. Non-Lost Time Accident . . . . . . . . . . . . . . . . . . . . . . . ._________. . .
.........
2. Lost Time Accident (Non-Fatal) . . . . . . . . . . . . . . . . . . _________ . .
..........
3. Lost Time Accident (Fatal) . . . . . . . . . . . . . . . . . . . . . . _________ . . .
..........
4. Days Lost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ._________ . . . .
..........
5. Manhours Worked . . . . . . . . . . . . . . . . . . . . . . . . . . . . ._________ . . .
..........
6. Frequency Rate per Million Manhours . . . . . . . . . . . . . _________ . .
..........
7. Severity Rate per Million Manhours . . . . . . . . . . . . . . . _________ . .
..........
8. Combined Frequency-Severity Rate . . . . . . . . . . . . . . . _________ . . .
..........
9. Days Lost (Old Cases) . . . . . . . . . . . . . . . . . . . . . . . . . ._________ . . .
..........
10. Number of Employees . . . . . . . . . . . . . . . . . . . . . . . . . ._________ . . . .
..........
COMPARED WITH THE SAME PERIOD LAST YEAR
Month-Year
NLTA
This
To
Mo.
Date
ACCIDENT
Non-Fatal
Fatal
This
To
This
To
Mo.
Date
Mo.
Date
Days
Lost
Total
This
Mo.
To
Date
1
This
Mo.
To
Date
Total
Manhours
This
To
Mo.
Date
Frequency
Rate
This
To
Mo.
Date
Severity
Rate
This
To
Mo.
Date
MGB Form No. 15-5
Republic of the Philippines
Department of Environment and Natural Resources
MINES AND GEOSCIENCES BUREAU
North Avenue, Diliman, Quezon City
By Shift
Month-Year
NLTA
This
To
Mo.
Date
ACCIDENT
Non-Fatal
Fatal
This
To
This
To
Mo.
Date
Mo.
Date
Days
Lost
Total
This
To
Mo.
Date
This
Mo.
To
Date
Total
Manhours
This
To
Mo.
Date
Frequency
Rate
This
To
Mo.
Date
Severity
Rate
This
To
Mo.
Date
Total
Manhours
This
To
Mo.
Date
Frequency
Rate
This
To
Mo.
Date
Severity
Rate
This
To
Mo.
Date
Total
By Factors Attributable to Occurrence of Accident
Month-Year
NLTA
This
To
Mo.
Date
ACCIDENT
Non-Fatal
Fatal
This
To
This
To
Mo.
Date
Mo.
Date
Days
Lost
Total
This
To
Mo.
Date
This
Mo.
Non-compliance
w/ standards
Unfit to work
Unsafe Working
Condition
Lack of Training/
Instruction
Use of Defective
Tools
Poor Planning/
Coordination
Others
Total
2
To
Date
MGB Form N0. 15-5
Republic of the Philippines
Department of Environment and Natural Resources
MINES AND GEOSCIENCES BUREAU
North Avenue, Diliman, Quezon City
By Months
Months
NLTA
This
To
Mo.
Date
ACCIDENT
Non-Fatal
Fatal
This
To
This
To
Mo.
Date
Mo.
Date
Total
This
To
Mo.
Date
Days
Lost
This
Mo.
To
Date
Total
Manhours
This
To
Mo.
Date
Frequency
Rate
This
To
Mo.
Date
Severity
Rate
This
To
Mo.
Date
January
February
March
April
May
June
July
August
September
October
November
December
Total
Approved By :
Noted By :
Prepared By :
___________________________
__________________________
______________________________
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