Instructions on how to properly fill in the WAIR

The purpose of the WAIR is to allow the DOLE to determine root cause and allow investigation into possible solutions to
workplace accidents lowering the financial and time cost to both the worker and employer. Please fill in all fields as completely
as possible. Visitors / guests to the workplace shall be categorized under "worker" for the purpose of the WAIR.
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1 If yes, then report to DOLE Regional Office using the DOLE-BQF-ALERT Form manually or online. Have the filled-in form
ready for the labor inspector. Contents of form may be relayed over phone if this would facilitate the speed of communicating
the event to DOLE.
2 Put an X if with or without Dangerous Occurrence
3 Refer to Reference Coding List D1-D18
4 Indicate if DOLE was notified within 24 hours (as noted in Item #1)
5 Put an X on the action taken by the Safety Officer.
6 Put an X where accident happened. Leave blank if not in given choices. Indicate location in the narration of the accident
7 Trade name of the business if different than the registered business name
8 SEC or DTI registered address of establishment.
9 SEC or DTI registered business name that hired and pays the wage/s of the involved worker
10 Refer to Reference Coding List Philippine Standard Industrial Classification, 2009
11 SEC or DTI registered business Owner/President/CEO/Chair
12 List number legally male and female workers hired and paid wages by the business (9) regardless of nature of employment
13 Date accident happened in Year, month, and day (Ex. 2019 Jan 01)
14 Time accident happened in 12 hour format (Ex. 10:00 AM, 11:30 PM)
15 Refer to Reference Coding list C1 to C9.2
16 Put an X on the appropriate answer
17 Describe all safety hazards present. Attach additional sheets as necessary.
18 Put an X on the appropriate answer
19 Describe all health hazards present. Attach additional sheets as necessary.
20 Describe other aggravating factors that may have aggravated the accident not previously described.
21 List materials and equipment that are primarily involved in the accident
22 Indicate time of start and end of shift and mark an X if AM or PM
23 Narrative of events leading to the accident. Attach pictures of the accident if available.

Section is for rereference only. NOT TO BE INCLUDED IN SUBMITTED DOCUMENT/S

 Instructions on how to properly fill in the WAIR (Page 2)
Tabulation of Equivalent Lost Work Days (LWD)
A. For loss of limb or parts of it either as a result of the accident or as an effect of surgery to address the injury from the accident.
If a portion of the bone of that finger or toe is involved, use the matrix below. If no bone is involved, classify as temporary total
disability and use actual days lost.
A.1. Hand and Fingers A.3. Arm
Part/s Affected LWD Part/s Affected LWD
Thumb 900 Any point above the
4,500
Index 600 elbow, including the joint
Middle 500 Any point above the wrist
3,600
Ring 450 or below the elbow
Little 400 Above = towards the shoulder, Below = towards the wrist
Hand at Wrist 3,000
A.4. Leg
A.2. Foot and Toes Part/s Affected LWD
Part/s Affected LWD Any point above the knee 4,500
Great Toe 600 Any point above the wrist
3,600
Other Toes 350 or below the elbow
Foot at ankle 2,400 Above = towards the hip, Below = towards the ankle
B. Impairment of Function or loss of use, as defined in DOH AO 2009-011, sustained in one accident
B.1. Loss of hearing impeding communication process essential to language, educational, social and/or cultural interaction
Part/s Affected LWD
In one ear 600
In both ears 3,000
B.2. Legal blindness if vision is 6/60 or worse B.3. Unrepaired Hernia
Part/s Affected LWD Part/s Affected LWD
In one eye 1,800 Regardless of part affected or
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In both eyes 6,000 extent of hernia
C. For loss of use without Amputations - permanently and totally incapacitates an employee from engaging in any gainful
occupation or which results in the loss or the complete loss of use of any of the following after an accident:
Part/s Affected LWD
(a) Both Eyes
(b) one eye and one hand, or arm, or leg or foot;
(c) any two of the following not in the same limb, hand, arm, foot, leg; 6,000
(d) permanent complete paralysis of two limbs;
(e) brain injury resulting in incurable imbecility or insanity.

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26 and 27 - Indicate if with machine damage and approximate total cost of the accident.
28 Indicate as DD/Month/YY (01 Jan 2018)
29 Indicate as HH:MM AM/PM (12:00 PM)
30 Refer to Reference Coding List C1-C16
31 Indicate the start time (HH:MM AM/PM) and end time (HH:MM AM/PM) of the worker's shift
32 Narrate events leading to the accident
33 Signature of the injured worker or employee's representative testifying that the narrative is correct.

Section is for rereference only. NOT TO BE INCLUDED IN SUBMITTED DOCUMENT/S

 Instructions on how to properly fill in the WAIR (Page 3)
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34 Indicate what part of the body is affected. Photos may be attached as hard copy or picture files.
35 Put an X on the side affected
36 Mark with an X the type of disability incurred by injured worker as determined by the attending physician, OH personnel or
trained safety officer (RULE 1051)
† Permanent Total Disability shall mean any injury or sickness other than death which permanently and totally
incapacitates an employee from engaging in any gainful occupation or which results in the loss or the complete loss of use
of any of the following in any of the following accident: (a) both eyes; (b) one eye and one hand, or arm, or leg or foot; (c)
any two of the following not in the same limb, hand, arm, foot, leg; (d) permanent complete paralysis of two limbs; (e) brain
injury resulting in incurable imbecility or insanity.
† Permanent Partial Disability shall mean any injury other than death or permanent total disability, which results in the loss
or loss of use of any member or part of a member of the body regardless of any pre-existing disability of the injured
member or impaired body function.
† Temporary Total Disability shall mean any injury or illness which does not result in death or permanent total or
permanent partial disability but which results in disability from work for a day or more.
37 Date (DD/MM/YYYY) when injured worker actually returned to work. Mark with ongoing if worker has not returned to
work at time of WAIR submission. A supplemental report on the worker status must be submitted upon return of the
worker or if there is final disposition of the worker.
38 List equipment or materials that are involved in the accident.
39 Refer to Reference Coding List C1-C9.2
40 Mark with an X all the hazards present at the time of the accident. Mark none if no safety hazard is present.
Unsafe Act and Condition as defined in the OSHC, Accident causes and Preventions
Unsafe Act - The human action that departs from a standard job procedure or safe practice, safety regulations or
instructions.
Examples: · Operating Equipment without Authority · improper PPEs or Using PPEs improperly
· Disregard of SOP or instructions · Horseplay
· Removing Safety Devices · Working in an unsafe posture
· Using Defective equipment · Willful intent to injure
Unsafe Condition - The physical or chemical property of a material, machine or the environment which could result in
injury to a person, damage or destruction to property or other forms of losses.
Examples: · Wet slippery floors · Live conductors without insulation
· Unstable stacking of materials · Equipment without machine guarding
· Protruding re-bars · Poor storage of combustible materials
41 Describe how the unsafe act or unsafe condition contributed to the accident.
42 Mark with an X all the hazards present at the time of the accident. Mark none if no health hazard is present.
Health Hazard Where a worker is liable to be exposed to any chemical, physical or biological hazard to such an extent as
ILO, Safety and Health in is liable to be dangerous to health, appropriate preventive measures shall be taken against such
Construction Convention,
1988 exposure.
43 Describe how the health hazard aggravates or contributes to the accident.
44 Factors that may have an effect on the accident but not directly involved in the accident. (Eg: Medication intake, etc.)
45 Action done to address the injured and decrease or remove the hazards
46 Steps taken to prevent the recurrence of the same or a similar accident
47 Projected date when corrective measure will be in place and functional.

Section is for rereference only. NOT TO BE INCLUDED IN SUBMITTED DOCUMENT/S

 Instructions on how to properly fill in the WAIR (Page 4)

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49 If with capability, images of the accident before and after placing of the corrective measures may be included in the report.
If the corrective measure is not in place by WAIR submission date, then corrective measure will be part of what will be
inspected by the labor inspector.
50 Name and signature of safety officer verifying that the corrective measures are physically in place. Write N/A if the
corrective measure is not in place by WAIR submission.
51 OH personnel or safety officer that conducted the investigation and filled in part of the report
52 Employer or representative that supplied part of the report
53 Date the Accident Investigation was done.

Document Submission Checklist to Regional Office

hard copy
excel file
pictures (if available at the time of WAIR submission)

Section is for rereference only. NOT TO BE INCLUDED IN SUBMITTED DOCUMENT/S

 DOLE-BQF-WAIR 1.02

REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF LABOR AND EMPLOYMENT
Regional Office No. _____

Workplace COVID-19 Prevention and Control Compliance Report

To be submitted at the end of the month
WAIR COVID-19
(Mark with an X the appropriate box)
Period Covered by Report January / 2021
Does the company have a policy on workplace COVID-19 prevention and control? x Yes No
Is the policy communicated to all workers and clients? x Yes No
Section I. Company Profile to be filled in by Employer or Representative ( as indicated in the DOLE Registration)
Establishment Name: Valley Bread Inc.
Address of Establishment: AE 220 Poblacion, Buyagan, La Trinidad, Benguet
Name of Employer: Eric Dion H. Espadero
Nature of Business: Bread Manufacturing
Number of Workers: Male Female Total
Principal 279 184 463
Subcontractor
Section II. Details of COVID-19 Prevention and Control
Report on Use of the Health Checklist
Worker Details: Screened: 463 Denied Entry: 0 Referred: 0 Death if any: 0
Guest / Client Details: Screened: 10 Denied Entry: 0 Referred: 0
BHERT Health Facility (specify)
Where were workers referred?
Others (specify)

Report on Testing (optional) performed

Did the establishment perform an optional diagnostic test prior to return to work of workers?
x Yes No. Please proceed to signature
If yes, mark type Type of Test Number of Test/s Done No. of Workers Confirmed to have COVID-19
of test done.  RT-PCR
 Gene Xpert
 Rapid Testing 6 0
 Other (Specify)
Total cost for the referrence month: P 12,000

Prestone N. Kalang-ad Judy Mae B. Padeo

OH Personnel / Safety Officer Employer / Representative
Signature beside printed name Signature beside printed name
Date: Date:

Note: WAIR COVID-19 to be submitted every month with or without any COVID-19 to DOLE office
with jurisidicton over the establishment, copy furnishing the DOH at the following email addresses:

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 DOLE-BQF-WAIR 1.02

health.covid.ndrrmc@gmail.com AND hembdiroffice@gmail.com

6 of 16
 DOLE-BQF-WAIR 1.02

OVID-19

ation)

7 of 16
 DOLE-BQF-WAIR 1.02

REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF LABOR AND EMPLOYMENT
Regional Office No. _____

Workplace COVID-19 Prevention and Control Compliance Report

To be submitted at the end of the month
WAIR COVID-19
(Mark with an X the appropriate box)
Period Covered by Report February / 2021
Does the company have a policy on workplace COVID-19 prevention and control? x Yes No
Is the policy communicated to all workers and clients? x Yes No
Section I. Company Profile to be filled in by Employer or Representative ( as indicated in the DOLE Registration)
Establishment Name: Valley Bread Inc.
Address of Establishment: AE 220 Poblacion, Buyagan, La Trinidad, Benguet
Name of Employer: Eric Dion H. Espadero
Nature of Business: Bread Manufacturing
Number of Workers: Male Female Total
Principal 279 184 463
Subcontractor
Section II. Details of COVID-19 Prevention and Control
Report on Use of the Health Checklist
Worker Details: Screened: 463 Denied Entry: 0 Referred: 0 Death if any: 0
Guest / Client Details: Screened: 10 Denied Entry: 0 Referred: 0
BHERT Health Facility (specify)
Where were workers referred?
Others (specify)

Report on Testing (optional) performed

Did the establishment perform an optional diagnostic test prior to return to work of workers?
x Yes No. Please proceed to signature
If yes, mark type Type of Test Number of Test/s Done No. of Workers Confirmed to have COVID-19
of test done.  RT-PCR
 Gene Xpert
 Rapid Testing 6 0
 Other (Specify)
Total cost for the referrence month: P 12,000

Prestone N. Kalang-ad Judy Mae B. Padeo

OH Personnel / Safety Officer Employer / Representative
Signature beside printed name Signature beside printed name
Date: Date:

Note: WAIR COVID-19 to be submitted every month with or without any COVID-19 to DOLE office
with jurisidicton over the establishment, copy furnishing the DOH at the following email addresses:

8 of 16
 DOLE-BQF-WAIR 1.02

health.covid.ndrrmc@gmail.com AND hembdiroffice@gmail.com

9 of 16
 DOLE-BQF-WAIR 1.02

OVID-19

ation)

10 of 16
 DOLE-BQF-WAIR 1.02

REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF LABOR AND EMPLOYMENT
Regional Office No. _____

Workplace COVID-19 Prevention and Control Compliance Report

To be submitted at the end of the month
WAIR COVID-19
(Mark with an X the appropriate box)
Period Covered by Report
Does the company have a policy on workplace COVID-19 prevention and control? Yes No
Is the policy communicated to all workers and clients? Yes No
Section I. Company Profile to be filled in by Employer or Representative ( as indicated in the DOLE Registration)
Establishment Name: Valley Bread Inc.
Address of Establishment: AE 220 Poblacion, Buyagan, La Trinidad, Benguet
Name of Employer: Eric Dion H. Espadero
Nature of Business: Bread Manufacturing
Number of Workers: Male Female Total
Principal 279 184 463
Subcontractor
Section II. Details of COVID-19 Prevention and Control
Report on Use of the Health Checklist
Worker Details: Screened: 463 Denied Entry: 0 Referred: 0 Death if any: 0
Guest / Client Details: Screened: 6 Denied Entry: 0 Referred: 0
BHERT Health Facility (specify)
Where were workers referred?
Others (specify)

Report on Testing (optional) performed

Did the establishment perform an optional diagnostic test prior to return to work of workers?
x Yes No. Please proceed to signature
If yes, mark type Type of Test Number of Test/s Done No. of Workers Confirmed to have COVID-19
of test done.  RT-PCR
 Gene Xpert
 Rapid Testing 0
 Other (Specify)
Total cost for the referrence month: P

Prestone N. Kalang-ad Judy Mae B. Padeo

OH Personnel / Safety Officer Employer / Representative
Signature beside printed name Signature beside printed name
Date: Date:

Note: WAIR COVID-19 to be submitted every month with or without any COVID-19 to DOLE office
with jurisidicton over the establishment, copy furnishing the DOH at the following email addresses:

11 of 16
 DOLE-BQF-WAIR 1.02

health.covid.ndrrmc@gmail.com AND hembdiroffice@gmail.com

12 of 16
 DOLE-BQF-WAIR 1.02

OVID-19

ation)

13 of 16
 DOLE-BQF-WAIR 1.02

REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF LABOR AND EMPLOYMENT
Regional Office No. _____

Workplace COVID-19 Prevention and Control Compliance Report

To be submitted at the end of the month
WAIR COVID-19
(Mark with an X the appropriate box)
Period Covered by Report January / 2021
Does the company have a policy on workplace COVID-19 prevention and control? x Yes No
Is the policy communicated to all workers and clients? x Yes No
Section I. Company Profile to be filled in by Employer or Representative ( as indicated in the DOLE Registration)
Establishment Name: Valley Bread Inc.
Address of Establishment: AE 220 Poblacion, Buyagan, La Trinidad, Benguet
Name of Employer: Eric Dion H. Espadero
Nature of Business: Bread Manufacturing
Number of Workers: Male Female Total
Principal 279 184 463
Subcontractor
Section II. Details of COVID-19 Prevention and Control
Report on Use of the Health Checklist
Worker Details: Screened: 463 Denied Entry: 0 Referred: 0 Death if any: 0
Guest / Client Details: Screened: Denied Entry: 0 Referred: 0
BHERT Health Facility (specify)
Where were workers referred?
Others (specify)

Report on Testing (optional) performed

Did the establishment perform an optional diagnostic test prior to return to work of workers?
x Yes No. Please proceed to signature
If yes, mark type Type of Test Number of Test/s Done No. of Workers Confirmed to have COVID-19
of test done.  RT-PCR
 Gene Xpert
 Rapid Testing 6 0
 Other (Specify)
Total cost for the referrence month: P 12,000

Prestone N. Kalang-ad Judy Mae B. Padeo

OH Personnel / Safety Officer Employer / Representative
Signature beside printed name Signature beside printed name
Date: Date:

Note: WAIR COVID-19 to be submitted every month with or without any COVID-19 to DOLE office
with jurisidicton over the establishment, copy furnishing the DOH at the following email addresses:

14 of 16
 DOLE-BQF-WAIR 1.02

health.covid.ndrrmc@gmail.com AND hembdiroffice@gmail.com

15 of 16
 DOLE-BQF-WAIR 1.02

OVID-19

ation)

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