Occupational Safety and Health (OSH) Program

Establishment’s Profile

Business Name
(as it appears in your
business permit)
Date Established
Complete business
address Barangay City/Municipality

Province Region

Official contact Mobile number/s: Landline or Fax Number:

details
Area code: Number:

Web address/URL: Company email address:

Authorized
Representative
(Owner/ Manager/
President)

Total Number of Total: Male: Female:

Employees

Business Establishment’s Philippine Standard Industrial

Classification Classification*
*For clarification, kindly
refer to PSIC.
Risk Classification Low
*Based on HIRAC Medium
High
Product Description
(ex. Garments, shoes,
electronics, N/A)
Description of
Services
Basic Components of Company OSH Program and Policy
(Republic Act No. 11058, Chapter IV, Section 12)

1. Company Commitment to Comply with OSH Requirements

2. General Safety and Health Programs:
a. Safety and Health Hazard Identification, Risk Assessment and
Control (HIRAC)
b. Medical Surveillance for early detection and management of
occupational and work-related diseases
c. First aid and emergency medical services
3. Promotion of Drug-Free Workplace, Mental health Services in the
Workplace, Healthy lifestyle
4. Prevention and Control of HIV-AIDS, Tuberculosis, Hepatitis B
5. Composition and Duties of the Health and Safety Committee
6. OSH Personnel and Facilities
7. Safety and Health Promotion, Training, and Education
a. Orientation of all workers on OSH
b. Conduct Risk Assessment, Evaluation, and Control
c. *Continuing training on OSH for OSH Personnel
d. *Work permit System
8. Toolbox/Safety Meetings, job safety analysis
9. Accident/Incident/illness Investigation, Recording and Reporting
10. Personal Protective Equipment (PPE)
11. Safety signages
12. *Dust control and management and regulation on activities such as
building of temporary structures and lifting and operation of electrical,
mechanical, communications systems and other requirements
13. Welfare Facilities
14. 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. Solid waste management system
16. Compliance with Reportorial Government Requirement (refer to Item 9.0)
17. Control and Management of Hazards (refer to Item 2-HIRAC)
18. *Prohibited Acts and Penalties for Violations
19. *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. Company Commitment to Comply with OSH Policy

________________________________________ do hereby commit to

comply with the requirements of R.A. 11058 and its Implementing Rules and
Regulations and the applicable provisions of the Occupational Safety and
Health Standards (OSHS).

(We/I) acknowledge the company’s obligation and responsibility to provide

appropriate funds for implementing this OSH program, including orienting and
training its employees on OSH, providing and disseminating IEC materials on
safety and health, providing PPE when necessary, and other OSH-related
requirements and activities. This program ensures the protection of our
workers and employees against injuries, illnesses, and death through safe
and healthy working conditions and environments.

We commit to conducting a risk assessment as required to prevent workplace

accidents and comply with other provisions of this OSH program. We are also
fully aware of the penalties and sanctions for OSH violations as provided for in
R.A. 11058 and its Implementing Rules and Regulations.

[Signature]
[Name]
[Designation]
[Date]

2. General Safety and Health Programs

a. Conduct of Risk Assessment
(Please use additional pages if needed. The Company’s Risk Assessment Matrix
may also be attached as a substitute.)

Risk Assessment Matrix

Priority:
(Likelihood of injury and
Task Hazard Risk Control
illness to occur)
[Low, Medium, High]

Example of Simple Risk Assessment:

Task Hazard Risk Priority Control
Drivers Occasional Fatigue and short rest Policy on a work
medium
deliver work long hours time between shifts break
products to Traffic Increased chance of
low Road safety program
customers congestion collision
Longer working hours medium Work breaks

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 Lifting of heavy Back injury from
Conduct proper
products lifting, reaching, high
orientation on lifting
carrying, etc.

b. Medical Surveillance
The company will require all employees to undergo a baseline or
initial medical health examination prior to being assigned to a potentially
hazardous activity. The examination will include but not be limited to the
following:
i. Routine: 1. CBC 2. Urinalysis 3. Stool Exam 4. Chest X-Ray
ii. Special: 5. Blood Chemistry 6. ECG 7. Others (Please Specify)
iii. Schedule of Annual Medical Examination: 8. 9. 10. 11.
Q Q

iv. Is random drug testing conducted? 12. Y When: _______ 13. N

es o

c. First Aid, Health Care Medicines, and Equipment Facilities

What health care facilities are provided? (e.g. treatment room, clinic, bed)
__________________________________________________________

3. and 4. Health Programs for the Promotion, Prevention, and Control

(Please indicate promotion health programs such as Drug-free Workplace in compliance with
Republic Act No. 9165 and Mental Health in compliance with Republic Act No. 11036, and
prevention and control health programs on HIV/AIDS in compliance with Republic Act No. 8504
and Republic Act No. 11166, Tuberculosis in compliance with Executive Order No. 187, Series of
2003, Hepatitis B in compliance with DOLE Advisory No. 05 Series of 2010)
________________________________________________________________
________________________________________________________________
________________________________________________________________

5. Composition and Duties of Occupational Safety and Health Committee

The OSH Committee of the company is responsible for planning,
developing, and implementing OSH policies and programs, monitoring and
evaluating OSH programs, and investigating all aspects of the work pertaining to
the safety and health of all workers. The employer shall establish an OSH
committee composed of the following:
Chairperson: ___________________________________
Name of Employer or Representative
Secretary: ___________________________________
Safety Officer of the workplace
Members: ___________________________________
Name of OH personnel (if applicable), contractor’s
safety officers (if applicable), and at least two
employees/workers' representatives.

All members of the OSH Committee shall perform their duties and
responsibilities according to the OSH law and its implementing guidelines

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including the submission of reports as required in the OSHS.

6. OSH Personnel and Facilities

(Please attach certificate of training/s prescribed by DOLE and use additional sheets as
necessary)

a. Safety Officer/s
Name of Safety Officer(s): Training and Number of Training
Hours

b. 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. Please attach certificate of training/s prescribed by DOLE and use additional
sheets as necessary.

Shift/Area/ Total Health Personnel & Facilities

Unit/ Number of Health Personnel Facilities
(First Aider, Nurse, (Treatment Room/Clinic)
Department Workers
Physician, Dentist)
per Area

7. Safety and Health Promotion, Education, and Training for Workers

(Please attach additional sheets as necessary)

a. Mandatory Safety Orientation of All Workers

Topics/matters of Number of Employees/
Date
orientation Workers in Attendance

b. Conduct of Risk Assessment, Evaluation, and Control

Personnel responsible for the conduct of risk Date
assessment (may include WEM)

c. Continuing training on OSH for OSH Personnel

OSH Personnel for training Date

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 d. Work Permit System (if applicable)
Discussion on the process of the work permit system being
implemented or to be implemented by the management of critical
activities. The job hazard analysis where said permit system is required.

Name of Person/s performing the

job:
Location of work:
Work Start Date: Work End Date:
Scope of Work:
Type of permit
(hot works, confined space, working
at heights, etc.)
Description of work to be
undertaken
(Workers’ details, responsible OSH
personnel, certifications needed, etc.)
Hazard identification and
control measures
PPE required
Emergency Preparedness

8. Conduct of Tool Box Meetings/ Safety Meetings

Personnel Who Conducts of Safety/ Schedule
Tool Box Meetings

9. Accident/Incident/Injury investigation recording and reporting

Any dangerous occurrence or major accident resulting in death or
permanent total disability shall be reported by the employer or the authorized
representative to the DOLE Regional Office within 24 hours from occurrence
using the prescribed form (Work Accident/Incident Notification).

After the investigation, the employer or the authorized representative shall

prepare and submit its work accident report using the prescribed form (WAIR).
Moreover, other work accidents resulting in 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 using the DOLE
prescribed form (WAIR).

All near-misses shall be recorded and reported. The OSH Committee shall
develop and review a system for notifying and reporting work accidents, including
near misses within the company, as necessary.

Kindly refer to below list of reports to be submitted to DOLE related

accident/Incident/Injury investigation recording and reporting:

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 Kind of report Date of submission
Accident Notification Within 24 hours from the time of
(Fatal/Serious Injury) occurrence
Work Accident/Injury Report (WAIR) Every 30th day of the month, regardless
of whether there were any accidents or
work-related illnesses in the workplace
Annual Exposure Data Report January 30 following the covered year
(AEDR)
Annual Medical Report (AMR) March 31 following the covered year

10. Provision and use of PPE

(Please use additional sheets as necessary)

The issuance of PPE shall be supplemented by training on its application,

use, handling, cleaning, and maintenance.
Types of PPE to be provided Number of workers provided

11. Safety Signage

The safety signages shall include warnings to workers, employees, and
the public about the hazards within the workplace.
(Please attach a picture of the safety signage provided.)

12. Dust control and management and regulation on activities such as

building of temporary structures and lifting and operation of electrical,
mechanical, communications systems and other requirements (if
applicable)
(Kindly attach dust control procedures, plans for temporary structures, permits applicable to the
operation of electrical, mechanical, and communications systems, and other requirements.)

13. 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 (Department Order No.
143, Series of 2015)
f. Ramps, railings, and the like

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 g. Other workers’ welfare facilities as
prescribed by OSHS and other related
issuances

14. Emergency and Disaster Preparedness

13.1 Written Emergency and Disaster Program Yes No
13.2 Drills Conducted
Type of Drills Date Responsible Person and
(fire, earthquake, etc) Position/Designation

15. Solid Waste Management System

Written Pollution Control Program: Yes No
Name of Pollution Control Officer:__________________________

16. Compliance with Reportorial Government Requirements

(Please refer to item 9.0)

17. Control and management of hazards

Based on accomplished HIRAC.

18. *Prohibited Acts and Penalties/Sanctions for violations of 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 of OSH.

Example of Company violation policies:

Safety Violation 1st offense 2nd offense 3rd offense
1. Not using issued PPE
2. Littering and loitering
3. Smoking in prohibited area
4. Illegal dismantling of safety
signages and paraphernalia
5. Not following safety rules

19. Cost of implementing company OSH program

The total amount of ____________________ (PhP______ ) is the
estimated annual amount for OSH program implementation for the
orientation/training of workers, safety officer, and OH personnel, provision and
maintenance of PPE, first aid medicine, other medical supplies, safety
signages and devices, fire safety equipment/tools, and the safety of
equipment (e.g., machine guards), etc.

OSH Item Estimated Cost/Year

PPEs

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 OSH Training
Safety Signages
Machine Guards and related equipment
Medical Examinations
Medical Supplies/Medicines
Others: Specify

ANNEX B.1:

WORKPLACE POLICY AND PROGRAM ON PROMOTING WORKERS'

HEALTH AND ENSURING PREVENTION AND CONTROL OF HEALTH-
RELATED ISSUES AND ILLNESS

_____________________________________ company is committed to

promoting and ensuring a healthy and safe working environment through its
various health programs for its employees. We shall comply with all regulations
and laws that guarantee workers' health and safety at all times.

The company shall ensure that workers’ 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 as proper nutrition and exercise
activities that are made available to the workers

The programs mentioned above shall comply with the Government’s

issuances on promoting a 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.

Signed:

_________________________ ________________________
Owner/Manager Employees’ Representative

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DATE: ___________________

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