_x000D_ Asurion Confidential
#
_x000D_ Asurion Confidential
#
_x000D_ Asurion Confidential
#
_x000D_ Asurion Confidential
#
If illness, fill in only gray blanksIf injury, completely fill in all blankx as 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 to the DOLE every 30th of the month, with or without any accident or reportable work-
related illness, including COVID cases, through the DOLE Establishment Report Systems (ERS).
This WAIR form may also be used as a supporting document for filling of claims.). For the month of OCTOBER 2024
Establishment: HOLISTIC APPROACH SYSTEMS INC./NCFL
1.
2. Address: HAS Bldg. Rodeo Drive Bel Air 2 Brgy. Don Jose Sta. Rosa Laguna
EMPLOYEER Nature of Business: Contracting Services
3. Name of Employer: MARILOU A. CORDON
Nationality: Filipino
4. Number of Employees: Male: 282 Female: 422 Total: 704
INJURED/ILL 5. Name: NO ACCIDENT
PERSON Age: Sex: Civil Status:
(Use WAIR-B for 6. Address:
multiple injured
Workers) 7. Average Weekly Wage: ₱ No. of Dependents:
8. Length of service prior to accident or illness:
9. Employment Status
10. Occupation: Years of Experience at Occupation:
11. Work Shift Start: Work Shift End: Hours of work/day: Day/week:
ILLNESS 12. Reportable Illness:
if reported illness is COVID-19, was it fatal?
13. Affected Worker's Work Location
14. Date Illness Begun: Date Returned to Work:
15. Days Lost: and/or Days Charged:
16. Date of accident: Time:
ACCIDENT 17. The Accident involved:
18. Description of accident: (Give full details on how accident occurred):
19. Was injured doing regular part of job at the time of accident: NO
If not, Why?:
NATURE & 20. Extent of Disability:
EXTENT OF
_x000D_ Asurion Confidential
#
If illness, fill in only gray blanksIf injury, completely fill in all blankx as appropriate
INJURY/IES 21. Nature of Injury:
Part/s of Body Affected:
22. Date Disability Begun: Date Returned to Work:
23. Days Lost: and/or Days Charged:
24. The Agency Involved:
CAUSE OF 25. The Agency part Involved:
ACCIDNET 26. Accident Type:
27. Unsafe Mechanical or Physical Condition:
28. The Unsafe Act:
29 Contributing Factor:
30. Preventive Measures (take or recommended):
CONTROL/ 31. Mechanical guards, personal protective equipment and other safeguards
PREVENTIVE
MEASURES 32. Were all safeguards in use? If not, why?
33. Control Instituted:
Engineering: Cost ₱
Administrative: Cost ₱
PPE: Cost ₱
34. Compensation: ₱
35. Medical and Hospitalization:
36. Burial:
MANPOWER 37. Time Lost on Day of Injury: Hrs. Mins.
38. Time Lost on subsequent Days: Hrs. Mins.
(treatment or other reasons)
39. Time on light work or reduced output: Day/s:
Percent Output:
40. Damage to Machinery and Tools (Driscribe):
MACHINERY
AND 41. Cost of repair or replacement: ₱
TOOLS 42. Lost Production Time: Cost ₱
43. Damage to Materials (Describe):
MATERIALS
44. Cost of repair or replacement: ₱
45. Lost Production Time: Cost ₱
46. Damage to Equipment (Drescribe):
EQUIPMENT 47. Cost of repair or replacement: ₱
48. Lost Production Time: Cost ₱
I/We hereby certify that the information above is accurate to the best of our knowledge. I/We understand that the data
contained herein is protected ny R.A. 10173 or the Data Privacy of 2012.
_x000D_ Asurion Confidential
#
If illness, fill in only gray blanksIf injury, completely fill in all blankx as appropriate
I/We hereby certify that the information above is accurate to the best of our knowledge. I/We understand that the data
contained herein is protected ny R.A. 10173 or the Data Privacy of 2012.
JULY 28,2025
Date
Reymun Derla Patrick De Leon R.N.
OH Personnel/ Safety Officer Employer/ Represenatative
_x000D_ Asurion Confidential
#
