Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

Bureau of Working Conditions
Intramuros, Manila

LABOR ADVISORY NO.

Series of 2022

EMPLOYER’S WORK ACCIDENT ILLNESS REPORT (WAIR)

Pursuant to Section 6.II.A. of the Guidelines on the Nationwide Implementation

of Alert Level System for COVID-19 Response issued by the IATF 27 February 2022 1,
the submission of WAIR COVID FORM online shall no longer be mandatory.
Establishments however, shall still submit the Employer’s Work Accident/Illness Report
(WAIR) to the DOLE every 30'h of the month, with or without any accidents or
reportable work-related illnesses, including COVID cases, through the DOLE
Establishment Report System (https://reports.dole.qov.ph) in compliance to the
provisions of Rule 1050 of the Occupational Safety and Health Standards of the
Philippines. The WAIR Form may also be used as a supporting document for filing of
claims.

For compliance.

SI
Secretar
y of Labor & £mployment
Dept.
OF C 8 Of 04 B 4CIT 8/

)§ March 2022 IIIIIIIIIIIIIIIIjtjjt|lIIlIlIIIIIIIIIIIIIIII

' https.//www.officiaIgazette.gov.ph/downloads/2022/02feb/20220227-lATF-GUIDELINES-RRD.pdf
DOLE/BWC/OHSD/IP-6 If illness, fill in only gray blank!
If injury, completely fill in all blanksas appropriate

Republic of the Philippines

Department of Labor and Employment
BUREAU OF WORKING CONDITIONS
Manila
WAIR- A
EMPLOYER’S WORK ACCIDENT/ILLNESS REPORT

(This report shall be submitted by the employer for every accident or illness to the Regional Office
having jurisdiction on or before the 20th day of the month following the date of occurrence.)

1. Establishment: Bits and Bytes

2. Address:
EMPLOYER Nature of Business: Retail of office machines, equipment, computers
3. Name of Employer:
Nationality:
4. Number of Employees: Male 38 Female 21 Total 5 9
INJURED 5. Name: Jason H. Llamo
PERSON Age: 36 Sex: M Married
(Use WAiR-B 6. Address:
for multiple
injured 7. Average Weekly Wage: P 3, 221.60 No. of Dependents: 3
Workers) 8. Length of service prior to accident or illness: 10 years
OCCUPATIONAL
HISTORY 9. Occupation: Head Technician Experience at Occupation: 6 years
10. Time of Shift: 8:00 AM-5 PM Hours of work/day: 8 hrs Day/Week: 6 days/week
ILLNESS
11. Reportable Illness:
RECORD
Pre ferred
12. No. of Affected Worker's by Sex: Male Female not to say

13. No. of Affected Worker's by Age: * 65 60-64 31-59

prcferre d
25-30 18-24 15-17 < 15 noI to say

14. Affected Worker's Work Location: Physically Reporting to Work

In Alternative Work Arrangement Hybrid/Combination
15. Control Instituted:
Engineering: POS t
COS t
Administrative: COSt
PPE:
16. Date of accident: July 1, 2022 Time: 9:38 AM
17. The accident involved: fractured left leg femur
ACCIDENT Personal Injury: yes Property Damage: none
18. Description of accident/illness (Give full details on how accident/illness occurred):
Got electrocuted and fell off the ladder while working on top of Laneco’s post; He was working for MDRRMO
(SND) to check on their CCTV that was not working
g

19. Was injured doing regular part of job at the time of accident or illness: Yes
If not, why?
NATURE & 15. Extent of Disability (Number of Worker): 1 Medical Treatment: surgery Fatal:
EXTENT OF Pemanent Partial: Temporary Partial: Permanent Total:
INJURY/IES 16: Nature of injury: (s ec IU lJet ei ence \n!›) Parts of Body Affected: left leg femur
17. Date Disability Begun: July 1, 2022 Date Returned to Work: January 11, 2023
DOLE/BWC/OHSD/IP-6 If illness, fill in only gray blanks
If injury, completely fill in aI| blanksas appropriate
18. Days Lost: 166 days or Days Charged:

19. N/A
CAUSE 20. N/A
OF 21. Electrocution; fell-off a ladder
ACCIDEN 22.
T 23. Did not wear safety harness
24.
25. Preventive Measures (taken or recommended): company requires field technicians to wear protective
harness whenever they climb ladders or working at heights
26. Mechanical guards, personal protective equipment and other safeguards none
PREVENTIVE
MEASURES 27. Were aI| safeguards in use? no If not, why? The said employee did
not wear the required safety harness during this particular instance

28. Compensation: given full salary and benefits during hospitalization and recuperation ₱12,469.60; total: ₱ 78,654.40
29. Medical and Hospitalization: ₱ 163, 527.00
30. Burial: n/a
31. Time Lost on Day of Injury: 165 days
MANPOWER Hrs. Mins.
32. Time Lost on Subsequent Days: Hrs. Mins.

(treatment or other reasons)

33. Time on light work or reduced output: Day:
Percent Output:
34. Damage to Machinery and Tools (Describe): N/A
MACHINERY
AND 35. Cost of repair or replacement: P N/A
TOOLS 36. Lost Production Time: COSt:

37. Damage to Materials (Describe): N/A

MATERIALS
38. Cost of repair or replacement: P N/A
39. Lost Production Time: COSt:

40. Damage to Equipment (Describe): N/A

EQUIPMENT
41. Cost of repair or replacement: I*N/A
42. Lost Production Time: N/A COSt:

I HEREBY CERTIFY on my honor to the accuracy of the foregoing information.

Date

Investigating Officer & Position Employer

 OOLE-BQF-WAIR

Republic of the Philippines

Department of Lahor and Emplcyment
Regional Office
,.,:.. /.‹.
. ... ‹p.‹.
Work Accident I Injury Repoit Patients' Data
Page
For multiple woiker involvement. Insert additional rows or pages as necessary.
WAIR-B
To be attached to WAIR-A.
Length of Lenqth of Stay Work 'Work
Date of Acciclent: Average Weekly Service in What is
at Current hours Days
Time of Accident: Employment wage Establishment
the current
Work per per
wr›rk
Name of Injured Worker Age Sex Occupation Status Philippine Pe.so In years assicned: Years MODthS Day Week
1 JASON H. LLAMO 36 M Head Technician Regulaar ₱ 2, 877.60 10 years Head tech. 10 0 8 6

VVe hereby ‹certify that the information above is accurate to the best of our knowledcle. W•. understand that this document is covered by the' Data Privacy of 2012 and
that fhe Data Protection Officer or Dala Privacy f7anual was cont:uIted on hcw to record, store and dispose this form.

OH Pers‹›nnel / S‹ifety Officer

Signature beside printed name Employer / Representative
Signature beside printed name