ACTIVITY INSTRUCTIONS:

DEADLINE: MARCH 03, 2025

TIME: DURING CLASS SCHEDULE
PREPARE AN OSH PROGRAM AND POLICIES OF A CHOSEN
COMPANY/BUSINESS/ESTABLISHMENT/ENTITY RELATED TO
ENGINEERING WORKS SPECIFICALLY IN MECHANICAL ENGINEERING
WORK RELATED (IF YOU ARE A MECHANICAL ENGINEERING STUDENT)
AND IN ELECTRICAL ENGINEERING WORK RELATED (IF YOU ARE AN
ELECTRICAL ENGINEERING STUDENT) AND IN COMPUTER ENGINEERING
WORK RELATED (IF YOU ARE A COMPUTER ENGINEERING STUDENT). THIS
IS AN INDIVIDUAL TASK NO DUPLICATIONS OF WORK.
ALSO FILL OUT THE DATA SHEETS PROVIDED FOR REFERENCES AS TO OSH
PROGRAMS AND POLICIES. INCLUDE SOURCES NAME AND ASSIGNATORY
OF CONTACT PERSON IN CHARGE.
 Occupational Safety and Health (OSH) Program of
(Company Name)
I. Complete Company Profile/ Project details

• Company Name: __________________________________________________

• Date Established: __________________________________________________
• Complete Address:
______________________________________________________________________
________________________________________________________________
• Phone and fax numbers
___________________________________________________________________
• Website URL/Email address
___________________________________________________________________
• Name of Company
Owner/Manager/President______________________________________________
• Total Number of Employees; _________ Male ________ Female _______
• Description of the business Pls specify
o Kindly check:
o Manufacturing:
______________________________
o Service:
______________________________
o Agri/fishing:
______________________________
o Wholesale/retail
______________________________
o Utilities ______________________________
o Banks and financial institution
_______________________
o Security Agency
o Maintenance
o Construction
o Others (Please specify)

• Product descriptions: (ex. Garments, shoes, electronics )______________________

• Description of services: _________________________________________________
 General Safety and Health Programs

Conduct of Risk Assessment

Kindly accomplish. Pls use additional pages if needed.

Risk Assessment Matrix

Priority: likelihood of
injury and illness to Control
Task Hazard Identified Risk Description
occur Measures
(low, medium, high)
First-Aid, Health Care Medicines and Equipment Facilities

• How may treatment rooms/first aid rooms are existing in your company? ______
• How many Clinics in the workplace? _______
• What hospital (s) are you affiliated with? _______

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 : _________________________________________________
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 of Safety officers representing the contractor or
subcontractor, as the case may be,

___________________________________________________
 Name of workers’ representatives who shall come from the
union, if the workers are organized, or elected workers through a
simple vote of majority, if they an unorganized.

(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 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 (pls attach latest OSH
committee minutes/report)

Yes ____ No ______

OSH Personnel and Facilities
Safety Officer

Name of Safety Officer(s): Training(s) (kindly include number of hours)

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.
Emergency Health Personnel and Facilities

Total number of Health Personnel & Facilities

Shift/Area/unit/ workers/area Health Personnel (First- Facilities
Department aider, Nurse, Physician, (Treatment Room/
Dentist) Clinic/ Hospital)

Safety and Health Promotion, training and education provided to workers

--Orientation of all workers on OSH

-Conduct of Risk Assessment, evaluation and Control

-*Continuing training on OSH for OSH Personnel

-*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 Number of Employees in Date

Training/Orientation attendance
Conduct of Risk Assessment (may include Date
WEM)

Conduct of Tool Box Meetings/ Safety Meetings if applicable

Conduct of Safety Meetings/Tool Box Meetings Date

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
Provision and use of PPE

Issuance of PPE shall be supplemented by training on the application, use, handling, cleaning
and maintenance.

PPE provided Number of Workers given

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.

Workers Facilities Provided:

FACILITIES PROVIDED? REMARKS

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
Emergency and Disaster Preparedness:

Written Emergency and Disaster Program Yes____ No_____

Types and number of Drills conducted

Type of Drills (fire, Date Responsible
earthquake) person/position

Control And Management Of Hazards

Refer to accomplished HIRAC. Provide separate sheet for this portion.

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)

(Pls 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
signages and paraphernalia suspension
5. Not following safety rules 3 day 5 day suspension Dismissal
suspension

Safety Violation 1st 2nd offense 3rd offense

offense
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