Occupational Safety and Health (OSH) Program
of _______________
I. Complete Company Profile / Project Details
Company Name:
Date Established:
Complete Address:
Phone/Fax Numbers:
Website URL/ E-mail Address:
Name of Company Owner/Manager/President:
Total Number of Employees: Male Female
Description of the Business
Kindly check which industry applies:
(Please specify the type on the blank provided)
□ Manufacturing:
□ Service:
□ Agri/Fishing:
□ Wholesale/Retail:
□ Utilities:
□ Banks and Financial Institution:
□ Security Agency:
□ Maintenance:
□ Construction:
□ Others (Please specify):
Product Descriptions: (ex. Garments, Shoes, Electronics )
Description of Services:
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II. Basic Components of Company OSH Program and Policy
(DO 198-18, Chapter IV, Section 12)
1.0 Company Commitment to Comply with OSH Requirements
2.0 General Safety and Health Programs
Safety and health Hazard Identification, Risk Assessment and Control
(HIRAC)
Medical Surveillance for early detection and management of occupational
and work related diseases
First-aid and emergency medical services
3.0 Promotion of Drug Free workplace, Mental health Services in the Workplace,
Healthy lifestyle
4.0 Prevention and Control of HIV-AIDS, Tuberculosis, Hepatitis B
5.0 Composition and Duties of health and safety Committee
6.0 OSH Personnel and Facilities
7.0 Safety and Health Promotion, Training and Education
Orientation of all workers on OSH
Conduct of Risk Assessment, evaluation and Control
*Continuing training on OSH for OSH Personnel
*Work permit System
8.0 Toolbox/Safety Meetings, job safety analysis
9.0 Accident/Incident/illness Investigation, Recording and Reporting
10.0 Personal Protective Equipment (PPE)
11.0 Safety signages
12.0 *Dust control and management and regulation on activities such as building of
temporary structures and lifting and operation of electrical, mechanical,
communications system and other requirements
13.0 Welfare Facilities
14.0 Emergency and disaster preparedness and response plan to include the organization
and creation of disaster control groups, business continuity plan, and updating the
hazard, risk and vulnerability assessment (as required)
15.0 Solid waste management system
16.0 Compliance with Reportorial Government Requirement (refer to Item 9.0)
17.0 Control and Management of Hazards (refer to Item 2-HIRAC)
18.0 *Prohibited Acts and Penalties for Violations
19.0 *Cost of Implementing Company OSH program
*(Applicable for medium to high risk establishments with 10 to 50 workers and low to high risk
establishments with 51 workers and above)
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1.0 Company Commitment to Comply with OSH Policy
________________________________________________ _________ do hereby commit
(Name of the Company)
to comply with the requirements of RA 11058 and DOLE Department Order 198-18 (its
Implementing Rules and Regulations) and the applicable provisions of the Occupational
Safety and Health Standards (OSHS).
We acknowledge the company’s obligation and responsibilities to provide appropriate funds
for implementing this OSH program including orientation and training of its employees on
OSH, provision and dissemination of IEC materials on safety and health, provision of Personal
Protective Equipment (PPE) when necessary and other OSH related requirements and
activities, to ensure the protection for our workers and employees against injuries, illnesses
and death through safe and healthy working conditions and environment.
We commit to conduct risk assessment as required to prevent workplace accidents as well as
comply with other provisions of this OSH program. That we are also fully aware of the
penalties and sanctions for OSH violations as provided for in RA 11058 and its Implementing
Rules and Regulations.
[Signature]
[President] / [Chief Executive Officer] / [Owner]
[Date]
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2.0 General Safety and Health Programs
2.1 Conduct of Risk Assessment
Kindly accomplish. Please use additional pages if needed. You may also attach your
Company’s Risk Assessment Matrix as substitute
Risk Assessment Matrix
Priority: likelihood
of injury and
Control
Task Hazard Identified Risk Description illness to occur
Measures
(low, medium,
high)
Example of Simple Risk Assessment
Task Hazard Risk Priority Control
Delivering Drivers work May be unable to call Need for
High
product to alone for help if needed helper
customers Drivers have to Fatigue, short rest time
Policy on
occasionally work between shifts Medium
work break
long hours
Drivers are often Increased chance of Road
in very congested collision Low safety
traffic program
Longer working hours Work
Medium
breaks
Drivers have to lift Injury to back from Given
boxes when lifting, reaching, proper
High
delivering product carrying, etc. orientation
on lifting
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2.2 Medical Surveillance
The company will require all employees to undergo a baseline or initial medical
health examination prior to assigning to a potentially hazardous activity. The
examination will include but not limited to the following:
a. Routine : ( ) CBC ( ) Chest X-ray ( ) Urinalysis ( ) stool exam
b. Special: ( ) Blood Chemistry ( ) ECG ( ) Others, please specify
__________________________________________________
c. Schedule of Annual medical examination: ( ) Q1 ( ) Q2 ( ) Q3 ( ) Q4
d. Is random drug testing conducted? Yes_____ when_______) No. ______
2.3 First-Aid, Health Care Medicines and Equipment Facilities
How many treatment rooms/first aid rooms are existing in your company? ______
How many Clinics in the workplace? __________________________________
What hospital (s) are you affiliated with? ________________________________
3.0 Promotion of Drug Free workplace, Mental Health Services in the
Workplace, Healthy lifestyle
This refers to the compliance to: DOLE Department Order No. 53-03 Guidelines for
the Implementation of a Drug-Free Workplace Policies and Programs; and RA 11036
on Mental Health.
4.0 Prevention and Control of HIV-AIDS, Tuberculosis, Hepatitis B
This refers to the compliance to: Department Order No. 102-10 Guidelines for the
Implementation of Human Immunodeficiency Syndrome (HIV) and AIDS Prevention
and Control in the Workplace Program; Department Order No. 73-05 Guidelines for
the Implementation of Policy and Program on Tuberculosis Prevention and Control in
the Workplace; and DOLE Advisory Np. 05, Series of 2010 Guidelines for the
Implementation of a Workplace Policy and Program on Hepatitis B.
3.0 And 4.0 - Health Programs for the promotion, prevention and control
**Prolonged Sitting and Standing
This refers to the compliance to: Department Order No. 178-17 Safety and health
Measures for Workers Who by the Nature of Their Work Have to Stand at Work; and
Department Order No. 184-17 Safety and Health Measures for Workers Who, By the
Nature of Their Work, Have to Spend Long Hours Sitting.
Kindly accomplish the policy template in Annex A.
(Attach individual policy statements)
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5.0 Composition and Duties of Safety and Health Committee
The SHC of the company is responsible to plan, develop and implement OSH policies and
programs, monitor and evaluate OSH programs and investigate all aspect of the work
pertaining to the safety and health of all the workers. SHC shall be composed of the following
in compliance with the law:
(a) For establishments with less than ten workers and low risk establishments with ten (10)
to fifty (50) workers. – A SO1 shall establish an OSH committee composed of the
following:
Chairperson :
Name of Company Owner or Manager
Secretary :
Name of Safety Officer of the Workplace
Member :
Name of at least one (1) worker,
preferably a union member, if organized
(b) For medium to high risk establishments with ten (10) to fifty (50) workers and low to high
risk establishments with fifty-one (51) workers and above. – The OSH committee of the
covered workplace shall be composed of the following:
Ex-officio :
Chairperson Name of Employer or his/her representative
Secretary :
Name of Safety Officer of the workplace
Ex-officio :
Members Name of Certified First-Aider/s
Name of OH nurse
Name of OH dentist, and OH physician, as applicable
Members:
Name/s of Safety Officer/s representing the contractor or
subcontractor, as the case may be,
Name/s of workers’ representative/s who shall come from the
union, if the workers are organized,
or elected workers through a simple vote of majority, if they are
unorganized.
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(c) Joint Coordinating Committee: For two (2) or more establishments housed under one
building or complex including malls.
Chairperson :
Name of Building owner or his/her representative such as the
building administrator
Secretary :
Name of Safety Officer appointed by the Chairperson
Members: :
Name of two (2) Safety Officers from the building selected to
the Joint OSH Committee
Name of two (2) workers’ representatives one from which must
be from a union if organized from any establishments under the
building
(All members of the HSC shall perform their duties and responsibilities by the OSH law and
its implementing guidelines.)
Safety and Health Committee Minutes/Reports submitted to DOLE (please attach latest OSH
committee minutes/report)
Yes ____ No _____
6.0 OSH Personnel and Facilities
6.1 Safety Officer
Safety Officer(s): (attach certificate of training/s prescribed by DOLE)(please use
additional sheets as necessary)
Training(s) (kindly include number of
Name of Safety Officer(s):
hours)
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6.2 Emergency Occupational Health Personnel and Facilities
List of competent emergency health personnel within the worksite duly complemented
by adequate medical supplies, equipment and facilities based on the total number of
workers. (Use additional sheet if necessary and attach all required training certificates
in this section.)
Emergency Health Personnel and Facilities
Health Personnel & Facilities
Total number of
Shift/Area/unit/ Health Personnel Facilities
workers/area
Department (First-aider, Nurse, (Treatment Room/
Physician, Dentist) Clinic/ Hospital)
7.0 Safety and Health Promotion, training and education provided to
workers
7.1 Orientation of all workers on OSH
7.2 Conduct of Risk Assessment, evaluation and Control
7.3 *Continuing training on OSH for OSH Personnel
7.4 *Work permit System
*(Applicable for medium to high risk establishments with 10 to 50 workers and low to
high risk establishments with 51 workers and above)
(Please attach additional sheets as necessary)
Name of OSH Training/Orientation No. of Employees in Attendance Date
Conduct of Risk Assessment (may include WEM) Date
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8.0 Conduct of Tool Box Meetings/ Safety Meetings if applicable
Conduct of Safety Meetings/Tool Box Meetings Date
9.0 Accident/Incident/Injury investigation recording and reporting
Any dangerous occurrence, major accident resulting to death or permanent total disability,
shall be reported by the company to the DOLE Regional Office within twenty four (24) hours
from occurrence using the prescribed form (Work Accident / Incident Notification).
After the conduct of investigation, the company shall prepare and submit work accident report
using the prescribed form (WAIR). Moreover, other work accidents resulting to disabling
injuries such as Permanent Partial Disability and Temporary Total Disability shall be reported
to the DOLE Regional Office within 30 days after the date of occurrence of accident using the
DOLE prescribed form (WAIR).
All near misses shall be recorded and reported. A system for notification and reporting of work
accidents including near misses within the company shall be developed and reviewed by the
OSH Committee as necessary.
(Kindly submit reports on the following: Work Accident /Injury Report (WAIR), Annual
Exposure Data Report (AEDR), Annual Medical Report (AMR)
Report Submitted Date
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10.0 Provision and use of Personal Protective Equipment (PPE)
Issuance of PPE shall be supplemented by training on the application, use, handling,
cleaning and maintenance.
PPE Provided Number of Workers Given
11.0 Safety Signage
The safety signages include warning to workers and employees and the public
about the hazards within the workplace.
Type of Safety Signage : (Kindly attach picture.)
12.0 *Dust control and management and regulation on activities such as
building of temporary structures and lifting and operation of electrical,
mechanical, communications system and other requirements
*(Applicable for medium to high risk establishments with 10 to 50 workers and low to
high risk establishments with 51 workers and above)
Kindly attach dust control procedures, plans on temporary structures, permits
app;icable for the operation of electrical, mechanical, communications systems and
other requirements
13.0 Workers Facilities Provided:
PROVIDED? REMARKS
FACILITIES
YES NO
a. Adequate supply of drinking water
b. Adequate sanitary and washing facilities
c. Suitable living accommodation (if
applicable)
d. Separate sanitary, washing and sleeping
facilities (if applicable)
e. Lactation station (in consonance with
DOLE D.O. 143-15)
f. Ramps, railings, and the like
g. Other workers’ welfare facilities as
prescribed by OSHS and other related
issuances
Page 10 of 13
14.0 Emergency and Disaster Preparedness
14.1 Written Emergency and Disaster Program Yes____ No_____
14.2 Types and number of Drills conducted
Type of Drills (e.g. Fire, Earthquake) Date Responsible person/position
15.0 Solid Waste Management System
15.1 Written Pollution Control Program: Yes:____ No: _____
15.2 Name of Pollution Control Officer:__________________________
16.0 Compliance with Reportorial Government Requirements (refer to item
9.0)
17.0 Control and management of hazards.
Refer to accomplished HIRAC
18.0 *Prohibited Acts and Penalties/Sanctions for violations on OSH
*(Applicable for medium to high risk establishments with 10 to 50 workers and low to high
risk establishments with 51 workers and above)
(Please attach existing company sanctions for violations on OSH)
Example of Company violation policies
Safety Violation 1st offense 2nd offense 3rd offense
1. Not using issued PPE Warning 3 Day suspension 5 day suspension
2. Littering and loitering Warning 3 Day suspension 5 day suspension
3. Smoking at prohibited area Warning 3 Day suspension 5 day suspension
4. Illegal dismantling of safety
Warning 3 Day suspension 5 day suspension
signage and paraphernalia
5. Not following safety rules 3 Day suspension 5 Day suspension Dismissal
Page 11 of 13
19.0 *Cost of implementing company OSH program
*(Applicable for medium to high risk establishments with 10 to 50 workers and low to high
risk establishments with 51 workers and above)
Php _______ ; Annual estimated amount for OSH program implementation to include but not
limited to the following: orientation/training of workers, safety officer, OH personnel, purchase
and maintenance of PPE, first aid medicine and other medical supplies, safety signages and
devices, fire safety equipment/tools, safety of equipment ( i.e machine guards,) etc.
OSH Item Estimated Cost/Year
PPEs
OSH Trainings
Safety Signages
Machine Guards and related
equipment
Medical examinations
Medical supplies/medicines
Others: Specify
Page 12 of 13
ANNEX A:
WORKPLACE POLICY AND PROGRAM ON PROMOTING WORKERS HEALTH AND
ENSURING PREVENTION AND CONTROL OF HEALTH-RELATED ISSUES AND
ILLNESS
________________________________________ company is committed to promote
and ensure a healthy and safe working environment through its various health programs for
its employees. We shall conform to the all issuances and laws that guarantee workers health
and safety at all times.
The company shall ensure that worker’s health is maintained through the following
company programs and activities:
a) Orientation and education of employees
b) Access to reliable information on illness and hazards at work
c) Referral to medical experts for diagnosis and management of illness or health-
related concerns
d) Provide health-related programs such proper nutrition and exercise activities are
made available to the workers
The above-mentioned programs shall comply with the Government’s issuances on
promoting healthy lifestyle, addressing mental health in the workplace and preventing and
controlling substance abuse.
In addition, company policies to protect workers’ rights arising from illness shall be
guaranteed. The company shall promote the following workers’ rights:
a) Confidentiality of information
b) Non-discrimination including non-termination
c) Work accommodation following a course of illness
d) Assistance to compensation
This policy is formulated for everybody’s information. The company is committed to
ensuring workers’ health and providing a healthy and safe workplace.
_____________________________ _____________________________
Owner /Manager Employees’ Representative
DATE: ___________________
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