Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

Intramuros, Manila
Certificate Number: AJA15-0048

ESTABLISHMENT REPORT ON COVID-19

_____________ REGION 1V-B MIMAROPA______________
(Region-PO/FO-Year-Month-Count)
(ex. NCR-MFO-2020-02-003)

Instructions:
1. Accomplish this form in two copies when filing a notice of: a) Flexible Work Arrangement or b) Temporary Closure.
The report is considered as duly filed when the complete list of workers affected is made part of the submission. Fields
with asterisks (*) should be accomplished by the company representative for COVID-19 Adjustment Measures Program
applications.
2. This form should be submitted to the DOLE Provincial/Field Office as soon as possible.
3. Page 1 should contain general information about the establishment and the number of workers affected.
4. Page 2 should enumerate the names of workers affected, their addresses and contact numbers, position title and
salary.
5. Total number of workers listed should equal the total number of workers affected as reported in this page.

A. Establishment Data

*Name of Establishment: FRONTLINERS SKILLS TRAINING AND REVIEW CENTER, INC.

*Floor/Bldg/No/Street/Subdivision: 2F BADJAO INN BLDG., 350 RIZAL AVENUE
*Barangay/City/Municipality: BGY. BANCAO-BANCAO, PUERTO PRINCESA CITY
Kind of Business/Economic SERVICES-TRAINING AND REVIEW CENTER
Activity/Principal Product:
*Number of Workers: Male: 2 Managerial Employees:
Female: Supervisory:
Total: 2 Rank and File:
Total:
*Date of Filing (mm/dd/yyyy) March 27, 2020

B. Summary of Affected Workers due to

B.1 Flexible Work Arrangement*
Type of Flexible Work Arrangement
No. of Workers Effectivity Date
to be Implemented
Covered/Affected (mm/dd/yyyy)
(Use code below, select only one)
2 March 16, 2020 FL
Codes for Flexible Work Arrangement Scheme:
 RW – Reduction of Workdays  FL - Forced Leave
 RE – Rotation of Employees  OTH - Others (Specify) ____________

B.2 Temporary Closure*

No. of Workers Effectivity Date Main Reason of Temporary Closure
Covered/Affected (mm/dd/yyyy) (Use code below, select only one)
2 March 16, 2020 Others – as per advisory regarding covid-
19 temporary closures on schools/No
students due to no scholarship from
TESDA
Codes for Main Reason for Temporary Closure:
 LM - Lack of Market/Slump in Demand  FLD - Financial Losses/Downsizing
 LRM - Lack of Raw Materials  OTH - Others (Specify) ____________
 I - Infection (COVID-19)

CERTIFICATION
This is to certify as to the accuracy of the data provided in this report.
*Name and Signature of Owner/Company Representative: Anna Diana A. Mendoza

Designation: Corporate President Fax No.:

Contact No.: 0928-502-1341 Email Address: frontliners350@yahoo.com

FOR DOLE USE ONLY:

Updates/Remarks: (e.g. resumption of normal business operations, reporting back of affected workers, etc.)

Name and Signature of DOLE Authorized Representative: Date Updated:

* Mandatory fields to be accomplished by the company representative for COVID-19 AMP applications.
 Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Intramuros, Manila
Certificate Number: AJA15-0048

LIST OF AFFECTED WORKERS DUE TO COVID-19

Instruction: If necessary, use additional sheets following the same format.
CONSENT NOTICE: By accomplishing this form, you agree that the information submitted shall be used solely for purposes of processing CAMP
applications pursuant to Labor Advisory No. 09-2020. We may likewise disclose your personal information to the extent that we are required to do so by the
Data Privacy Act of 2012. As a general rule, we may only keep your information until such time that we have attained the purpose by which we collect them.
Under the foregoing circumstances and to the extent permissible by applicable law, you agree not to take any action against the DOLE for the disclosure
and retention of your information.

Profile of Affected Workers

Name of Employment Salary

Worker* Contact Status (indicate
No. Age* Sex* Home Address* Designation whether per
(Last Name, First Number* (regular, hour, day,
Name, M.I.) contractual, etc.) week, or month)
Calabia, 27 Male Bgy. Bancao- 0977- Trainer/Processing Regular P8,000.00
1
Hervin T. bancao, PPC 854-1993 Officer
Rosal, Rogiel 26 Male Bgy. Fernandez, 0909- Trainer Regular P8,000.00
2
C. PPC 037-6134
3

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30
* Mandatory fields to be accomplished by the company representative for COVID-19 applications.