WE CARE FOR OUR PEOPLE. WE CARE FOR OUR ENVIROMENT.

Registered Company Name

Service Provider/Sub-contractors

Date Established :
Owner/Employer Name :
Nature of Business :
Business Address :

Contact Numbers/Fax Number :

Focal Person/Coordinator :
Contact Numbers :
Email Adress :

Please attached Proof of Evidence for the following;

BIR Registrations Number :
SEC Registrations Number :
Mayors Permit Number :
Sanitary Permit Number :

I hereby certify that above information are true and correct to the best f my knowledge.
Prepared/Submitted By:

Position/ Designation Email Address Cellphone bumber

117 Technology Avenue SEZ Laguna Technopark Biñan Laguna Philippines 4024
 Occupational Safety and Health Compliance Checklist Page 2 of 4

Frequency of Conforming
Requirements Monitoring Yes No Status

1. DOLE OSH Program

1.1 COVID-19 Workplace Safety and Health (WSH) Program Need to Provide in alligned to DTI-
in compliance to DTI-DOLE Interim Guidelines
Annual ✓ DOLE Interim Guidelines
1.2 OSH Program submitted/received by DOLE with Company Commitment to comply with OSH Already provided and Submitted to
requirements
Annual ✓ DOLE last July 02, 2021
2. General Safety and Health Programs
No established HIRAC Procedures and
Hazard Identification Risk Assessment and Control (HIRAC) Annual ✓ Forms yet
Medical Surveillance
a. Annual Physical Examination Annual ✓ Schedule on the Last Quarter of 2021
b. Special Examination Annual ✓ Schedule on the Last Quarter of 2021
c. Random drug-testing for establishments w/ > 10 workers Annual ✓ Schedule on the Last Quarter of 2021
Ongoing Purchase request for Medical
First Aid and Emergency Medical Services (Provider Contract) ✓ Services
3. Policy and Program on Promotion of the following;
1 Drug Free Workplace Policy & Program Annual ✓
2 Mental Health Policy Annual ✓
3 Healthy Lifestyle Policy Annual ✓
4 Alcohol Free Workplace Policy Annual ✓
5 Sexual Harassment Policy Annual ✓
6 Smoke Free Workplace Policy Annual ✓
7 HIV/Aids Workplace Policy Annual ✓
8 Tuberculosis Workplace Policy Annual ✓
9 Hepatitis Workplace Policy Annual ✓
10 Accident Incident Investigation Procedure Annual ✓ Need to provide Internal Procedure
11 Emergency Preparedness and Response Procedure Annual ✓ Need to provide Internal Procedure
12 OSH Risk Assessment Policy Annual ✓ Need to provide Internal Procedure
13 Good Housekeeping/5S Policy/Procedure/Guidelines Annual ✓ Need to provide Internal Procedure
Need to resubmit due to additional
4. Registration of Establishments (Rule 1020, OSHS) One time ✓ Floor Area and Acknowledgement of
President/Owner
5. Composition of OSH Committee Annual ✓ Must be received by DOLE
6. OSH Personnel and Facilities and appointment certificate signed by the employer
Must provide Appointment Certificates
Safety Officer/s Annual ✓ from Human Resources
OH Personnel
Expired First Aid Trainings - Need to
a. First Aider Annual ✓ reschedule with Redcross
Shall undergo 40hr training from
b. Nurse Annual ✓ OHNAP
d. Physician Annual ✓ Covered under Company Health Card
c. Dentist Annual ✓ Covered under Company Health Card
Health Facilities
a. Emergency medicines Annual ✓
b. Treatment room Annual ✓
c. Clinic w/ sufficient number of clinic beds Annual ✓ To provide Memorandum of Agreement
between Incenter and Service Provider.
d. Hospital (or w/ MOA) Annual ✓
e. Dental Clinic (or w/ MOA) Annual ✓
7. Safety and Health Promotion, Training and Education
- Orientation of all workers on OSH (8hrs) Annual ✓
No established HIRAC Procedures and
- Conduct of HIRAC (submit copy) Monthly ✓ Forms yet
- Continuous Training of OSH Personnel(Refresher Courses) Monthly ✓
No established Work Permitting System
- Work Permit System Education/OSHModule Annual ✓ yet.
Condcuted every week for HSE
8. Conducted Safety Orientation/toolbox meeting(Minutes of Meeting) Monthly ✓ Advisories
9. OSH Reports
 Frequency of Page 3
Conforming of 4
Requirements Monitoring Yes No Status
- Report on Safety and Health Organization/s (RSHO ) Annual ✓
- Annual Medical Report (AMR) Annual ✓
Submission every 30th of the month,
- Employer's Work Accident/Injury Exposure Data (for every disabling injury ) (WAIR ) Monthly ✓ With or without case
- Annual Work Accident/Injury Exposure Data (whether or not there is an accident/illness ) (AEDR ) Annual ✓
- Work Accident Incident Form - COVID -19 Monthly ✓
10. Provision of appropriate/applicable PPE to workers
(evidence of purchase, monitoring, records, or any proof of issuance)
- Provision of PPEs Quarterly ✓
- No Cost to Employee ✓
- Tested and Approved N/A
11. Provision for Safety Signage's
- Visible safety signage's Annual ✓ Included in The Desktop background
- Understandable signage's to all workers Annual ✓
12. Workers Welfare Facilities (Please submit proof/evidence of compliance)
- Adequate supply of safe drinking water Annual ✓
- Adequate sanitary and washing facilities Annual ✓
- Suitable living accommodation if applicable Annual N/A
- Separate sanitary, washing and sleeping facilities for all gender, if applicable as may be Annual ✓
- Lactation Station Annual ✓
- With designated area for lactation station in the workplace Annual ✓
With facilities such as refrigerator/cooler, table and chair, sink with running water or access to washing
- facilities
Annual ✓
Observes Lactation Equivalency Guide if a designated area for workplace lactation station is not
- feasible due to peculiar workplace circumstances
Annual ✓
Document is already ready for Review
- With workplace breastfeeding policy Annual ✓ and approval
- Observes lactation period Annual ✓
- With Certificate of Exemption issued by DOLE for qualified establishments (D.O. 143, s. 2015 ) One time N/A
13. Emergency Evacuation Drills
Quarterly/
- Emergency Medical Drills
Semi Annual ✓
Conduct of Emergency, Fire and
Quarterly/
- Fire drill
Semi Annual ✓ Medical Drill is still not allowed - Bureau
of Fire Protection
Quarterly/
- Earthquake drill
Semi Annual ✓
14. Solid Waste Management System Procedure Annual ✓ No drafted Internal Procedure yet
15. Control and Management of Hazards Procedure Annual ✓ Refers to HIRAC Procedure
16. Dust Control and Management System procedure Annual ✓ No drafted Internal Procedure yet
17. Cost of Implementing company OSH Programs is provided Annual
Part II-B.2
No establish procedure for OSH Hazard
19. No Imminent Danger Situation (condition that could cause death or serious physical harm ) Annual ✓ Identification
20. Fire Safety Inspection Certificate (FSIC ) issued by BFP Annual ✓
- Fire Safety Maintenance Report ✓ No Fire Safety Maintenance Report yet
21. Fire Protection Equipment/Facilities (Rule 1940, OSHS )
- Fire extinguishers (inspected monthly) Monthly ✓ No Internal Checklists established yet
- Fire hoses (properly mounted, accessible and maintained) Quarterly ✓ No Internal Checklists established yet
Monthly/Quar
- Fire detection devices (installed and functional)
terly ✓
- Emergency Lights Monitoring and Inspection Monthly ✓ No Internal Checklists established yet
22. Emergency Exits (2 per floor with no obstructions) (Copy of Drawings/As-built Plans/Floor Plans? Picture)
- Illuminated Exit Signs are installed and other mandated requirements Quarterly ✓ Some Exit routes must need to be updated
- Illuminated Exit routes are installed and other mandated requirements Quarterly ✓ Some Exit routes must need to be updated
No one-way/directional markings
23. Adequate Aisles/Passageways (sufficient width and height and with signs and markings) Annual ✓ posted on hallways
24. Proper Office Spacing (between workers and machines)(Rule 1060, OSHS) Annual ✓
25. Permit/s to Operate for industrial machines covered by
DOLE TSI (Rule 1160, 1170, 110, 1210. 1220, 1230/1240, OSHS )
Annual N/A
- Boiler - permit to operate Annual N/A
- Pressure Vessel - permit to operate Annual N/A
- Internal Combustion Engine - permit to operate Annual N/A
 Frequency of Page 4
Conforming of 4
Requirements Monitoring Yes No Status
- Elevators and other Related Equipment - with permit to operate Annual N/A
- Power Piping Lines Inspection - permit to operate Annual N/A
- Crane and Hoist Equipment - permit to operate Annual N/A
- Turbine - permit to operate Annual N/A
- Electrical Wiring Installation Inspection (Rule 1210) (Cert. of electrical inspection) Annual N/A
Workplace is still under set-up and
26. Good Housekeeping/5S Implementation (conditions of floors, walls and storage rooms) (Rule 1060, OSHS) Annual ✓ ongoing Renovation
Workplace is still under set-up and
27. Proper Handling and Storage of Materials (e.g. appropriate labels, dotting and storage)(Rule 1150 & 1090, OSHS) Annual ✓ ongoing Renovation
No WEM Testing conducted as of the
28. Work Environment Measurement Conducted (maintenance of WEM monitoring report)(Rule 1070, OSHS) Annual ✓ moment
No WEM Testing conducted as of the
29. Adequate Lighting (in Work Areas, in aisles and passageways) (Rule 1070, OSHS on Illumination) Annual ✓ moment
No WEM Testing conducted as of the
30. Noise Exposure Control (provide appropriate PPE or isolation of work area)(Rule 1070, OSHS) Annual ✓ moment
No WEM Testing conducted as of the
31. Radiation Exposure Control (provide PPE, examination of work area) Annual ✓ moment
32. Waste Disposal System (waste receptacle and its removal; drainage system) Annual ✓ No Hauler yet for Electronic Waste
No WEM Testing conducted as of the
33. Proper Ventilation (provision of natural or artificial air supply)(Rule 1070, OSHS) Annual ✓ moment
No WEM Testing conducted as of the
34. Airborne Contaminants Control (Rule 1070, OSHS) Annual ✓ moment
35. Defined Procedure in Performing Hazardous Work (Rule 1120, OSHS) Annual N/A
36. Approved Work Permit System Annual ✓ No established Work Permitting System yet.
37. Provision of safety measures guidelines/policy when operating machines (railing or casing of moving parts) (Rule
1200, OSHS)
Annual N/A
38. Provision of control/safety measures guidelines/policy when Hazardous Materials are used (Rule 1090, OSHS) Annual N/A
39. Stated Safety Measures guidelines/policy when Working on Electrical Installations Annual N/A
40. Safety Guidelines/Policy When Perfuming Gas and Electric Welding and Cutting Operations (Rule 1100) Annual N/A
41. With DOLE-approved Construction Safety and Health Program (CSHP) Annual N/A
42. For contractors/subcontractors in the construction industry
- Registration with Philippine Contractors Accreditation Board (PCAB) Annual N/A
- Construction Safety Signage's Annual N/A
- Construction Heavy Equipment (CHE) Testing Annual N/A
- Construction Heavy Equipment Operator TESDA Certified Annual N/A
- Construction Worker's Skills Certificate for Critical Occupations Annual N/A
- Defined Safety Program When in use of Scaffoldings Annual N/A
- Available ECC Logbook Annual
- Sanitary Permit Annual ✓
- Health Permit of Workers Annual N/A
- List of Safety Data Sheet Annual N/A
43. Fire Safety Clearance- Hot work Annual N/A
Note: * OSH Programs considered pre approved once stamp received by DOLE RO/FO having jurisdiction over the company