Incident Report Form

Use this form to report any workplace accident, injury, incident, close
call or illness.
Return completed form to the Operations Supervisor, or Management.

This is documenting an:

*

Lost Time/Injury First Aid Incident Close

Call Observation

Details of person injured or involved (to be filled in by person

injured / involved if possible)

Person Completing Report: Romeo Dela Cruz Date: 09-7-22

Person(s) Involved: John C. Santos
Department/ Designation: Computer Department - Assembler

Event Details

Date of Event:_October 5 – 8, 2022 Location of Event: Assembler

Area

Time of Event: 9:00 AM

Witnesses: Maureen Legaspi

Description of Events : Tardiness

On October 5 – 8, 2022 at PC Bulacan Company - Computer

Department, the company supervisor filed a formal complaint against
Mr. John C Santos. The supervisor has been observing the constant
tardiness of Mr. John C. Santos. When he gave him a warning, Mr.
John C. Santos answered back rudely making the supervisor
humiliated in front of their colleagues.

The supervisor cannot tolerate such attitude of any personnel and

therefore told us to give Mr. John C. Santos appropriate sanctions for
his unwanted behavior. Please refer to the detailed report of the
incident at the Human Resource Office of PC Bulacan Computer
Department.
Was event / injury caused by an unsafe act (activity or
movement) or an unsafe condition (machinery or weather)?
Please explain:

The company supervisor quote:

“Our company may lose good customers with such attitude of Mr.
John C. Santos as it may reflect the kind of service our company
provides and therefore may decrease probable sales and opportunities.
It has never been acceptable for this company to tolerate such act and
therefore subjected Mr. John C. Santos for a disciplinary action.
We have been ordered to temporarily suspend Mr. John C. Santos
regarding this incident.”

TO BE COMPLETED ONLY IF LOST TIME/INJURY OR FIRST AID

WAS REQUIRED
Type of injury
sustained:
Cause of lost time/
injury or first aid:
Was medical Yes_____ No_____
treatment If yes, name of hospital or physician:
necessary?

Signature of Employee:_ John C. Santos Date: 10-9-2022

Signature of Supervisor/ Trainer: Romeo Dela Cruz Date: 10-9-2022
 ACTION FORM
(To be filled out by the Institution Trainer)

TO MR. PEDRO CASTRO

Manager
PC Bulacan
Baliuag, Bulacan

Dear Sir,

This letter is with regards to the complaint and sanctions filed

against Mr. John C. Santos, last October 5 – 8, 2022. We understand
that you are only applying standard rules and regulations set by the
company concerning such issues. It is a regret of this institution to
learn that our trainee did not follow company procedures. We would
like to apologize with what happened and at the same time would like
to inform you that we validated this incident with Mr. John C. Santos.
He admittedly accepted the report.
We told him to do counseling with our Guidance Counselor
regarding his attitude problem and he willingly agreed to the idea. He
now understands that his personal problem should not be brought into
workplace since it will make him lose his focus on the job.
We hope that after the suspension, he will be given another
chance by your company to make up as an improved individual.
Please extend my regards an apology to Mr. Randy Garcia and we
truly hope that our relationship will not be tainted with the said
incident.

Thank you for your understanding

Respectfully yours,

ROMEO DELA CRUZ

TRAINER