ST ND RD
ST ND RD
Office Production/Shop
1st Shift 2nd Shift 3rd Shift
Male: ____________________
160 _______________
68 _____________
30 _______________
62
Female: __________________
156 _______________
74 _____________
22 _______________
60
Total: ____________________
316 _______________
142 _____________
52 _______________
122
Name: __________________________________________________________________________________
Address: ________________________________________________________________________________
( ) Occupational health physician
Name: __________________________________________________________________________________
Address: ________________________________________________________________________________
(X ) Occupational health nurse
Name: __________________________________________________________________________________
Joseph Karlo Corachea, Rn
Address: Brgy.
________________________________________________________________________________
Alangilan, Batangas City
d. The occupational health physician/practitioner/nurse/personnel conducts an inspection of the workplace:
a. The employer provides a treatment room/medical clinic in the workplace with medicines and facilities:
(X) Yes _____________ ( ) No _________________
( ) others, please specify ______________________________________________________________________
___________________________________________________________________________________________
d. The following occupational health personnel of this establishment have undergone training in occupational health and
safety/first aid:
( ) occupational health physician
(X ) occupational health nurse
(X) first-aider
( ) others, please specify _________________________________________________________________
___________________________________________________________________________________
1. Pre-placement ______________
0 ________
0 __________
0
2. Periodic ______________
316 ________
316 __________
316
3. Return-to-work ______________
0 ________
0 __________
0
4. Transfer ______________
0 ________
0 __________
0
5. Special ______________
0 ________
0 __________
0
6. Separation ______________
0 ________
0 __________
0
Stool Exams Blood Test ECG Others
1. Pre-placement ______________
0 __________
0 __________
0 ________
0
2. Periodic ______________
316 __________
316 __________
20 ________
0
3. Return-to-work ______________
0 __________
0 __________
0 ________
0
4. Transfer ______________
0 __________
0 __________
0 ________
0
5. Special ______________
0 __________
0 __________
0 ________
0
6. Separation ______________
0 __________
0 __________
0 ________
0
Skin:
( ) allergy _____________
0 ____________
0 ____________
0
( ) dermatoses
( ) infection as folliculitis/ _____________
0 ____________
0 ____________
0
absecess/paronychia
( ) Others _____________
0 ____________
0 ____________
0
Head:
(X) migraine headache _____________
10 ____________
22 ____________
32
( ) tension headache _____________
0 ____________
0 ____________
0
( ) Others _____________
0 ____________
0 ____________
0
Eyes:
( ) Error of refraction _____________
0 ____________
0 ____________
0
( ) Bacterial/Viral conjunctivities _____________
0 ____________
0 ____________
0
( ) Cataract _____________
0 ____________
0 ____________
0
( ) Others _____________
0 ____________
0 ____________
0
Respiratory:
( ) Bronchitis _____________
0 ____________
0 ____________
0
( ) Pronchial Asthma _____________
0 ____________
0 ____________
0
( ) Pneumonia _____________
0 ____________
0 ____________
0
( ) Tuberculosis _____________
0 ____________
0 ____________
0
( ) Pneumoconiosos _____________
0 ____________
0 ____________
0
( ) Others _____________
0 ____________
0 ____________
0
Gastrointestinal:
( ) Gastroenteritis/Diarrhea _____________
0 ____________
0 ____________
0
( ) Amoebiasis _____________
0 ____________
0 ____________
0
( ) Gastritis/Hyperacidity _____________
0 ____________
0 ____________
0
( ) Appendicitis _____________
0 ____________
0 ____________
0
( ) Infectious Hepatitis _____________
0 ____________
0 ____________
0
( ) Liver Cirrhosis _____________
0 ____________
0 ____________
0
( ) Hepatic Absecess _____________
0 ____________
0 ____________
0
( ) Cancer (Hepatic/Gastric) _____________
0 ____________
0 ____________
0
( ) Others _____________
0 ____________
0 ____________
0
Genito-Urinary:
(X) Urinary Tract Infection _____________
0 1
____________ ____________
1
( ) Stones _____________
0 ____________
0 ____________
0
( ) Cancer _____________
0 ____________
0 ____________
0
( ) Others _____________
0 ____________
0 ____________
0
Reproductive:
(X) Dysmenorrhea _____________
0 ____________
7 ____________
7
( ) Infection (Cervicitis) _____________
0 ____________
0 ____________
0
(Vaginitis) _____________
0 ____________
0 ____________
0
( ) Abortion (Spontaneous) _____________
0 ____________
0 ____________
0
(Threatened) _____________
0 ____________
0 ____________
0
( ) Hyperemesis Gravidarum _____________
0 ____________
0 ____________
0
( ) Uterine Tumors _____________
0 ____________
0 ____________
0
( ) Cervical Polyp/Cancer _____________
0 ____________
0 ____________
0
( ) Ovarian Cyst/Tumors _____________
0 ____________
0 ____________
0
( ) Sexually-Transmitted Diseases _____________
0 ____________
0 ____________
0
( ) Hernia (Inguinal) _____________
0 ____________
0 ____________
0
(Femoral) _____________
0 ____________
0 ____________
0
( ) Others _____________
0 ____________
0 ____________
0
Neuromuscular/Skeletal/Joints:
( ) Peripheral Neuritis _____________
0 ____________
0 ____________
0
( ) Torticollis _____________
0 ____________
0 ____________
0
( ) Arthritis _____________
0 ____________
0 ____________
0
( ) Others _____________
0 ____________
0 ____________
0
Infectious Diseases:
( ) Influenza _____________
0 ____________
0 ____________
0
( ) Typhoid/Paratyphoid Fever _____________
0 ____________
0 ____________
0
( ) Cholera _____________
0 ____________
0 ____________
0
( ) Measles _____________
0 ____________
0 ____________
0
-4-
( ) Mumps _____________
0 ____________
0 ____________
0
( ) Tetanus _____________
0 ____________
0 ____________
0
( ) Malaria _____________
0 ____________
0 ____________
0
( ) Schistosomiasis _____________
0 ____________
0 ____________
0
( ) Herpes Zoster _____________
0 ____________
0 ____________
0
( ) Chicken Fox _____________
0 ____________
0 ____________
0
( ) German Measles _____________
0 ____________
0 ____________
0
( ) Rabies _____________
0 ____________
0 ____________
0
( ) Others _____________
0 ____________
0 ____________
0
13. Keeping of Medical-Records of Workers (Please check) (X) done ( ) not done
16. Hazards in the Workplace: (Please check and give details of the active substance)
a. Chemicals Hazards:
( ) dust (Ex. Silica dust) ______________________
N/A ______________________
0
( ) liquids (Ex. Mercury) ______________________
N/A ______________________
0
( ) mist/fumes/vapors
(Ex. Mist from paint spraying) ______________________
N/A ______________________
0
( ) gas (Ex. CO, H2S) ______________________
N/A ______________________
0
( ) others (please specify) ______________________
N/A ______________________
0
b. Physical Hazards:
( ) noise ______________________
None / In Good Condition ______________________
0
( ) temperature/humidity ______________________
None / In Good Condition ______________________
0
( ) pressure ______________________
N/A ______________________
0
( ) illumination ______________________
None / In Good Condition ______________________
0
(X) radiation/ultraviolet/microwave ______________________
Desktop / Laptop ______________________
316
( ) others (please specify) ______________________
None ______________________
0
None (Not allowed to
c. Biological Hazards: work if not physically fit
( ) Viral ______________________
or need to WFH) ______________________
0
( ) Bacterial ______________________
None ______________________
0
( ) Fungal ______________________
None ______________________
0
( ) Parasitic ______________________
None ______________________
0
( ) Others ______________________
None ______________________
0
d. Ergonomic Stress:
( ) Exhausting physical work ______________________
None ______________________
0
( ) Prolonged standing ______________________
None ______________________
0
( ) Low Back Pain ______________________
None ______________________
0
( ) Unfavorable work posture ______________________
None ______________________
0
( ) Static/monotonous work ______________________
None ______________________
0
(X) Others, specify ______________________
Prolonged Sitting ______________________
0
(Already Managed)
Submitted by:
Noted by:
__________________________________________________
For: Eva Macatol - HR Manager
Employer