NOT FOR SALE

Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT
RKS FORM
Page 1 of
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_____________________________________ Certificate Number: AJA15-0048 _______
2020
(Region-PO/FO-Year-Month-Count) Certificate
(ex. NCR-MFO-2020-02-003)
Instructions:
1. Accomplish this form in two copies when filing a notice of: a) Flexible Work Arrangement; b) Temporary Closure; c)
Retrenchment or Reduction of Workforce; or d) Permanent Closure.
The report is considered as duly filed when the complete list of workers affected is made part of the submission. Fields with
asterisks (*) should be accomplished by the company representative.
2. This form should be submitted to the DOLE Provincial/Field Office as soon as possible in the case of adoption of flexible work
arrangement or temporary closure.
2.1. For establishments that will retrench or permanently close, the form should be submitted 30 days prior to the effectivity of
termination.
3. Page 1 should contain general information about the establishment and the number of workers affected.
4. Page 3 should enumerate the names of workers affected, their addresses and contact numbers, position title and salary.
5. Total number of workers listed should equal the total number of workers affected as reported in this page.
ESTABLISHMENT REPORT FORM1
□
ADOPTION OF ALTERNATIVE WORK SCHEMES □ TERMINATION OF EMPLOYEES
A. ESTABLISHMENT INFORMATION
Date of Filing (mm-dd-yyyy): m m - d d - y y y y
*Name of Establishment:

*Floor/Bldg/No/Street/Subdivision:
*Barangay/City/Municipality:
*Kind of Business/Economic
Activity/Principal Product:
*Company TIN:
*Company SSS Number:
*Number of Workers: Male: 4 Managerial Employees:
Female: 6 Supervisory:
Total: 10 Rank and File:
Total:

B. SUMMARY OF AFFECTED EMPLOYEES DUE TO

B.1 Flexible Work Arrangement*
Period of Adoption of Alternative Work Type of Flexible Work Primary Reason
Scheme (AWS) Arrangement of Adoption of
No. of Workers
End to be Implemented AWS
Covered/Affected Start
(mm/dd/yyyy) (Use code below, select (Use code below,
(mm/dd/yyyy)
only one) select only one)
10 3/17/2020 5/1/2020 T GR

Codes for Type of Flexible Work Arrangement Scheme:

 TOE – Transfer of employees to another branch or PCE – Partial closure of establishment where some
outlet of the same employer unit or departments of the establishment are continued
 AOE – Assignment of employees to other function or while other units or department are closed
position in the same or other branch or outlet of the  JR – Job rotation alternately providing employees with

1
This form is pursuant to Section 7 of DOLE Labor Advisory No. 17, Series of 2020 issued on 16 May 2020.

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same employer work within the workweek or within the month
 RNW – Reduction of Normal Workdays/Hours per day  FDL - Forced Leave
or week  T – Telecommuting (wok from home)
  OTH - Others (Specify) ____________

Codes for Primary Reason for Adoption of AWS:

 LM - Lack of Market/Slump in Demand  FL - Financial Losses
 LRM - Lack of Raw Materials OTH - Others (Specify) ____________
 GR – Government Regulation
 
B.2 Temporary Closure*
Primary Reason of Temporary
Period of Adoption of Alternative Work Scheme
No. of Workers Closure
Covered/Affected Start End (Use code below, select only
(mm/dd/yyyy) (mm/dd/yyyy) one)
10 5/2/2020 8/23/2020 FL

Codes for Primary Reason for Temporary Closure:

 LM - Lack of Market/Slump in Demand  FL - Financial Losses
 LRM - Lack of Raw Materials  OTH - Others (Specify) ____________
 GD – Government Decision

B.3 Retrenchment/Reduction of Workforce*

No. of Workers Effectivity Date Primary Reason of Retrenchment
Covered/Affected (mm/dd/yyyy) (Use code below, select only one)

B.4 Permanent Closure*

Effectivity Date of
No. of Workers Primary Reason of Permanent Closure
Termination
Covered/Affected (Use code below, select only one)
(mm/dd/yyyy)

Codes for Primary Reason Retrenchment (B.3) / Permanent Closure (B.4):

 LM - Lack of Market/Slump in Demand  RDS - Reorganization/Downsizing
 UCP – Uncompetitive Price of Products  R – Redundancy
 CI – Competition from Imports  CMM – Change in Management/Merger
 HCP – High Cost of Production  LRM – Lack of Raw Materials
 LC – Lack of Capital  MR – Increase in Minimum Wage Rate
 PD – Peso Depreciation  OTH - Others (Specify) ____________
 FL – Financial Losses


CERTIFICATION
This is to certify as to the accuracy of the data provided in this report.

____________________________________________________________________
Signature Over Printed Name of Owner or Company Representative and Date
Designation: Mobile No.:

Telephone No.: E-mail Address:

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Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Intramuros, Manila

Certificate Number: AJA15-0048

LIST OF AFFECTED WORKERS
Instruction: If necessary, use additional sheets following the same format.

CONSENT NOTICE: By accomplishing this form, you agree that the information submitted shall be used solely for purposes of monitoring and planning. We may likewise disclose your personal information to the extent
that we are required to do so by the Data
Privacy Act of 2012. As a general rule, we may only keep your information until such time that we have attained the purpose by which we collect them. Under the foregoing circumstances and to the extent permissible by
applicable law, you agree not to take
any action against the DOLE for the disclosure and retention of your information.

Name of Worker* Home Address* Employm

Sex ent
Birthday* Hous 4,000
N Middl * Contact Designati Status*
Last First (dd/mm/ e City/ Email Address* -
o. e (F/ Street Brgy. Province No* on* (regular,
Name Name yyyy) Numb Municipality 10,00
Name M) contractua
er 0
l, etc.)
Bacar Rolly Usman 23/11/1969 M Sittio Pikit North 093631231 [email protected] Teacher Contractual 8,500
1
Punol Cotabato 87
Gania Omar Daud 26/10/1987 M Lagpan Polloc Parang Maguindan 093694901 [email protected] Teacher Contractual 5,000
2
ao 29
Ibrahim Salahod Ibrahi 22/9/1997 M San Sarmien Parang Maguindan 093666066 salahodinibrahimlaho@gmail. Teacher Contractual 6,500
3
in m Antonio to ao 39 com
Makalimp Fahad Munda 2/1/1988 M Lugay- Bagua 1 Cotabato Region XII 097762892 fahadmakalimpas2020@gma Liason Contractual 5,500
4
as s lugay 78 il.com Officer
Gersaba Emmie Jacaba 15/7/1995 F Lagpan Polloc Parang Maguindan 099727058 [email protected] Teacher Contractual 5,000
5
ao 76
Guyo Normin Mamp 13/6/1998 F Manggah Polloc Parang Maguindan 093565085 [email protected] Teacher Contractual 6,500
6
a en an ao 92
Guyo Saimon Mamp 7/3/1996 F San Sarmien Parang Maguindan 094583143 [email protected] Teacher Contractual 8,500
7
a en Antonio to ao 91
Mampen Noraine Ali 3/9/1984 F San Sarmien Parang Maguindan 096589584 [email protected] Teacher Contractual 6,500
8
Antonio to ao 34

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Piang Munera Guiaba 16/10/1993 F Mareges Tapaya Sultan Mastura Sultan 095572158 [email protected] Teacher Contractual 5,000
9
r n Kudarat 80
Romanca Nasiba Parail 18/3/1989 F Lagpan Polloc Parang Maguindan 093694901 [email protected] Teacher Contractual 8,500
10
p ao 29 om

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15

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*a *Mandatory fields to be accomplished by the company representative