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MGB15-4 Template
MGB15-4 Template
MGB15-4 Template
15-4
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PREVENTIVE MEASURES
31. Remediation (undertaken or recommended) : ______________________________
32. Provision for Mechanical Guards; Personal Protective Equipment etc. are adequately
met___________________________________________________________
RESPONSIBILITY
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MANPOWER
35. Compensation : __________________ Amount : ___________________
36. Medical and Hospitalization :
_____________________________________________
37. Burial : _____________________________
38. Time Lost on Day of injury ___________ hours ___________ mins. __________
39. Time Lost on Subsequent Days due to treatment or follow ups _________________
hours _____________________ mins. _____________________
40. Time on light work spent : ______________________ hrs. _________ mins._____
ACCIDENT COST
Machinery and Tools Damage
41.
____________________________________________________________________
42. Cost of Repair or Replacement : _________________________________________
43. Lost Production Time : _______________________ Cost :__________________
44. Damage to Materials (Describe)
________________________________________________________________________
______________________________________
Materials
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Date
FRED VINCENT BALDOMERO
Project Engineer
NOTE: Copies to be sent to the Department of Labor and Employment and to the Mines
and Geosciences Bureaus Regional Offices, copy furnished - MGB-Central Office, by the
operator/employers.