Occupational Safety and Health (OSH) Program of

(Name of Station)
I. Complete Company Profile/ Project details

 Station Name:________________________________________________________
 Date Established: ____________________________________________________
 Complete Address: ___________________________________________________
 Phone and fax numbers: _______________________________________________
 Website URL/Email address: ____________________________________________
 Name of Dealer_______________________________________________________
 Total Number of Employees: _________ Male __________ Female _________
 Description of the business Pls specify
o Kindly check:
o Manufacturing: Oil and Gas Industry
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: Petroleum Products
 Description of services:

Petron Corporation is the largest Oil Refining and Marketing Company in the
Philippines. Our 180,000 barrel-per-day oil Refinery in Bataan process crude oil into
a full range of petroleum products and petrochemical feed stock.

Through about 2,400 service stations nationwide – the largest service station network
in the country – we retail gasoline, diesel and kerosene to motorists. Supplying nearly
40% of the country’s oil requirements, our world class products and services fuel the
lives of millions of Filipinos.
Petron is dedicated and passionate about its vision to be the leading provider of total
customer solutions in the energy sector and its derivative businesses.

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 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 Station Commitment to Comply with OSH Policy

______ ____________________________________________________ do hereby

commit
(Name of Station)
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 station’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] ______________________________

[Name] _________________________________
[Dealer] / [Owner]
[Date]: _________________________________

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Page | 4
2.0 General Safety and Health Programs

2.1 Conduct of Risk Assessment

Kindly accomplish. Pls use additional pages if needed. You may also wish to attach your Company’s Risk Assessment Matrix as substitute

HAZARD IDENTIFICATION RISK ASSESSMENT

NO OF PEOPLE AT RISK
TYPE OF ACTIVITY

PROBABILITY

RISK DEGREE
SEVERITY
AREA /
JOB STEP / TASK HAZARD RISK EXISTING CONTROL MEASURES

RPN
ACTIVITIES

         
Work Desk work R PC radiation Impaired / Blurring vision Use of LCD Monitors 4 1 4 4 LOW
Station
Musculoskeletal disorders and
Poor, awkward illness (neck, shoulder, back Use of ergonomically designed office
10 1 2 2 LOW
posture disorder, mental fatigue, furniture & equipment
headache, nausea)

Musculoskeletal disorders and

Repetitive Use of ergonomically designed office
illness (tendonitis, carpal 10 1 2 2 LOW
motion furniture & equipment
tunnel syndrome)
Cramped work Mental Fatigue, Headache,
Housekeeping 10 1 2 2 LOW
space Nausea
Poor
Eye strain, Headache, Nausea Replacement of lighting fixtures 10 1 2 2 LOW
illumination
Protruding Injury, Cuts, Lacerations Housekeeping 10 2 4 8 MEDIUM
objects (nails,
chipped
objects, bolts)

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 Short circuits /
Shock, Fire - injury, Injury Insulation of electrical wires/Migger Testing 10 3 2 6 LOW
Bare wire

Punctures / Cuts 4 2 3 6 LOW

Use of cutter and Pointed / Sharp
NR Awareness / Presence of mind
stapler Objects
Eye Injury 4 2 3 6 LOW

Inefficient air
Discomfort, Heat Stress, Fire,
conditioning / Regular cleaning of ACU 4 1 2 2 LOW
Injury
ventilation
Inefficient
Eye strain, Headache Replacement of lighting fixtures 10 1 2 2 LOW
illumination

Slippery floor Slip, Trip, Fall - injury Signages, Use of PPE 10 2 4 8 MEDIUM

Heights Fall - injury, Injury, Disability Use of handrails and Ladders 2 4 2 8 MEDIUM

Obstruction on
passageways
Installation of Warning Signage / Regular
(debris, holes, Trip, Fall, Cut, Lacerations 10 2 4 8 MEDIUM
Housekeeping
cracks, nails,
bolts, etc.)
Protruding
General Office objects (nails, Housekeeping, Regular check-up of office
Office Area R Injury, Cuts, Lacerations 10 2 4 8 MEDIUM
Occupation chipped equipment
objects, bolts)
Loose and/or
Bare electrical Fire - injury, burns Insulation of loose and bare electrical wires 10 3 2 6 LOW
wires
Communicable
Disease, Illness Posting of Medical bulletins and Annual PE 10 2 3 6 LOW
Disease
Insects, Disease, Illness, Food
Regular Housekeeping 10 2 2 4 LOW
Rodents poisoning
Chronic respiratory illnesses,
Dusts Housekeeping and use of Dust Mask 10 3 2 6 LOW
Asthma
Aerosols, Pneumoconiosis, Injury,
Proper storage of awareness 10 3 2 6 LOW
Insecticides Poisoning

Damaged office
Injury, Cuts Regular inspection of office building 4 2 2 4 LOW
building

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 (leaking roof,
broken
window/door
seal, cracks,
etc.)
Animosity,
Injury, Bruises Recreation, summer outing, sportsfest 10 1 2 2 LOW
Violence
Excessive Mental fatigue, Headache,
Posting of Health Bulletins 10 1 2 2 LOW
working hours Illness

Uneven Stress, Mental fatigue, Regular review and rotation of employee

10 1 2 2 LOW
Employee, Visitor workload Headache, Illness work load
NR
Behaviour
Extraneous
Regular review and rotation of employee
stress (extra- Stress, Mental fatigue 10 1 2 2 LOW
work load
curricular)
Poor hygiene
(employees and Disease, Illness, Fumes provision of Comfort room 10 1 2 2 LOW
visitors)
Radiation from
Eye strain, stress LCD monitors 4 1 4 4 LOW
PC
Repetitive
incorrect hand Use of ergonomically designed office
Carpal Tunnel Syndrome 4 2 2 4 LOW
motion in using furniture & equipment
PC keyboard
Improper
posture / Back injuries, musculo-skeletal Use of ergonomically designed office
10 1 2 2 LOW
Awkward disorders furniture & equipment
Receivables / position
Payables / R
Poor
Accounting Eye strain Replacement of lighting fixtures 10 1 2 2 LOW
Illumination
Communicable
disease Serious Illness, Death Posting of Medical bulletins and Annual PE 10 2 3 6 LOW
infection

Slippery Installation of Warning Signages and

Bruises, Bodily injuries 4 2 3 6 LOW
surfaces housekeeping

Tripping due to Bruises, Bodily injuries Housekeeping 4 2 2 4 LOW

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 Improperly
strewn PC and
electrical wires
Electrocution
due to faulty Death, Shock, heart attack,
Insulation of loose and bare electrical wires 4 4 2 8 MEDIUM
electrical paralysis
wirings
Fire resulting
from
Burns, Injury, Death, Property Regular Housekeeping and Proper Waste
accumulated 4 4 2 8 MEDIUM
Damage disposal
combustible
materials
Use of comfort
  R Surface Hazards Bruises, Bodily injuries Housekeeping 10 2 3 6 LOW
room
Height (TT
Bodily injuries, Disability Railings/Awareness 2 4 2 8 MEDIUM
inspection)
Tank truck Vapor
Chronic respiratory illnesses Use of PPE (Gas mask) 2 3 2 6 LOW
inspection (seals, inhalation
R
product level, Death, injury and property
product quality) Fire Deployment of fire extinguisher 10 5 2 10 MEDIUM
damage
Slippery surface Bodily injury Housekeeping 2 2 3 6 LOW
Spillage Injury Use of drip pans 2 2 2 4 LOW

Slippery tank Non-slip coatings, non-slip safety shoes,

Bruises, Injuries 2 2 3 6 LOW
Pre-Tank surface awareness
Truck
Discharging Determining UGT Flammable Awareness on basics of fire and static
R Burns, Injury 2 3 2 6 LOW
ullage/sounding Liquids electricity
Dermatoxic,
Skin disorder, rashes,
carcinogenic Use of chemical resistant gloves, use of 2 2 2 4 LOW
respiratory illness
Chemicals long-sleeved jackets
Radiation from
Impaired / Blurring vision Use of LCD monitor 4 1 4 4 LOW
PC
Poor or
Computation of
R awkward
ullage Carpal Tunnel Syndrome /
posture, Use of ergonomic equipment 4 1 2 2 LOW
Back injuries
repetitive
motion

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 Deployment of Back injuries, sprained/pulled
R Over-exertion Proper lifting 4 2 3 6 LOW
20# FEX muscles
Back injuries, sprained/pulled
Over-exertion Proper lifting 4 2 3 6 LOW
Deployment of muscles
R
spill kit Slippery
Bruises, sprain Use of safety shoes, housekeeping 2 2 3 6 LOW
surface

Over-exertion Head Injuries, bruises Wearing of hard hat and safety shoes 2 2 3 6 LOW
Deployment of
R Spillage Injury Use of drip pans 2 2 3 6 LOW
discharging hose
Slippery
Hand, foot or leg injuries Wearing of safety shoes 2 2 3 6 LOW
Tank Truck surface
Discharging Spillage Injury Use of drip pans 2 2 3 6 LOW
Fire while
discharging due
Burns, injury, death Turn off cellphone 2 4 2 8 MEDIUM
to activated
cellphone
Discharging of Inhalation of
R Respiratory illness Use of organic vapor mask 2 3 2 6 LOW
product to UGT vapor
Splashing of
Eye injury Use of safety goggles 2 2 2 4 LOW
product
Dermatoxic,
Skin disorder, rashes,
carcinogenic Wearing of gloves 2 2 2 4 LOW
respiratory illness
Chemicals

Skin disorder/irritation, Burns, Follow proper filling procedure

Chemicals 10 2 3 6 LOW
rashes, cancer Use of nitrile gloves

Product Fumes Use of organic mask respirator if there is

Chronic respiratory illnesses 10 3 2 6 LOW
inhalation discomfort
Pump Product
R
Island Dispensing
Use of aluminum containers
Flammable
Awareness on static electricity and basics
liquids Burns, injury, death 10 4 2 8 MEDIUM
of fire
(gasoline)
Use appropriate uniform

Fire due to Burns, injury, death Turn off cellphone 10 4 2 8 MEDIUM

Page | 9
 activated
cellphone

Follow proper filling procedure

Spillage Injury 10 2 3 6 LOW
Knowledge on Emergency Response

Discomfort, heat stroke, heat

Heat exhaustion, heat cramp, Use appropriate uniform 10 1 3 3 LOW
fatigue, skin burns,

Awkward
posture /
Musculoskeletal disorders and
Excessive
illness (neck, back & shoulder Awareness on ergonomics 10 1 3 3 LOW
bending,
disorder, mental fatigue, etc.)
twisting and
over reaching
Bump from the Awareness
Bruises, bodily injury, death 10 2 2 4 LOW
vehicle Wearing safety shoes

Wearing safety shoes

Slippery surface Bruises, bodily injury Installation of Warning Signages and 10 2 2 4 LOW
housekeeping

Spillage Injury Use of drip pans 4 2 3 6 LOW

Flammable
Burns, Injury Deployment of FEX 4 2 2 4 LOW
Liquids
Back injuries, sprained/pulled
Over exertion Proper lifting 2 1 3 3 LOW
muscles
Musculoskeletal disorders and
Repetitive Use of ergonomically designed office
Lube Bay Vehicle Change illness (tendonitis, carpal 2 1 3 3 LOW
R motion furniture & equipment
Area Oil tunnel syndrome)
Fall (boom lift
Death, disabling injury Awareness 2 1 3 3 LOW
deficiency)
Splashing of oil Eye injury Use of eye protection 2 2 2 4 LOW
Air Chronic respiratory illnesses,
particulates / Eye injuries / diseases, Use of organic mask respirator 2 2 3 6 LOW
pollutants blindness

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 Slippery surface Bruises, bodily injury Wearing of safety shoes 4 2 2 4 LOW
Back injuries, sprained/pulled
Over exertion Proper lifting 2 1 3 3 LOW
muscles
Musculoskeletal disorders and
Repetitive Use of ergonomically designed office
illness (tendonitis, carpal 2 1 3 3 LOW
motion furniture & equipment
Vehicle Repair R tunnel syndrome)
Slippery surface Bruises, bodily injury Wearing of safety shoes 4 2 2 4 LOW
Flammable
liquids Burns, Injury Deployment of FEX 4 2 2 4 LOW
(gasoline)

Discomfort, heat stroke, heat

Heat exhaustion, heat cramp, Use of cotton clothing 2 2 2 4 LOW
fatigue, skin burns,

Working at
Bodily injuries, Disability Awareness 2 2 2 4 LOW
height
Slippery, greasy
Slips, trips, bruises Wearing of safety shoes & Housekeeping 2 2 2 4 LOW
surface
Obstructions on
passageways
Fall - injury, Slips, trips -
(pails, debris, Housekeeping 2 2 3 6 LOW
injury, bruises
holes, bolts,
Wash Bay etc.)
Vehicle Washing   Sudden water
Area
burst due to
Injury Use of appropriate clothing, eye protection 2 2 2 4 LOW
excessive
pressure
Musculoskeletal disorders and
Repetitive illness (tendonitis, nausea,
Use of ergonomically designed equipment 2 2 3 6 LOW
motion headache, eye strain, mental
fatigue)
Awkward
posture /
Musculoskeletal disorders and
Excessive
illness (neck, back & shoulder Use of ergonomically designed equipment 2 2 2 4 LOW
bending,
disorder, mental fatigue, etc.)
twisting and
over reaching

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 Pump Fall Death, injury Use of scaffolding and PPE (fall arrest
Island system & hard hat)
Repair of
Training requirement for erector
defective canopy NR 2 4 2 8 MEDIUM
and spreader

Slips, fall, Discomfort, injury, burns, No work allowed during heavy rain.
Works during rain NR electrocution, sprains 4 3 2 6 LOW
poor visibility
Splashing of Skin irritations, eye injury, Use of gloves and eye protection
Repair of products, Flash burn, death Use of bump cap
NR Fire, Conduct LOTOTO 4 4 2 8 MEDIUM
defective pump

Fall Death, injury Use of scaffolding and PPE (fall arrest

system & hard hat)
Training requirement for erector 4 4 2 8 MEDIUM
Replacement of
NR
defective lightings
Electrocutions Death, injury Use of appropriate PPE (gloves, clothing)
Conduct LOTOTO 4 4 2 8 MEDIUM

UGT Area Musculoskeletal disorders and

Repetitive illness (tendonitis, nausea,
Use of ergonomically designed equipment 4 2 2 4 LOW
motion headache, eye strain, mental
fatigue)
O-ring
replacement of NR Awkward
UGT fill pipe posture /
Musculoskeletal disorders and
Excessive
illness (neck, back & shoulder Use of ergonomically designed equipment 4 2 2 4 LOW
bending,
disorder, mental fatigue, etc.)
twisting and
over reaching
Garbage Improper Injury on back, muscle sprains Awareness on ergonomics
Area Lifting/handling, 4 1 2 2 LOW
Garbage
NR
segregation Dermal Contact Allergies, burns, skin Use of gloves, use of long-sleeved jackets
with garbage irritations, skin cancer 4 1 2 2 LOW

First person Run to nearest Body injuries due to slip, trip

to response NR Slippery Surface Safety shoes 2 2 2 4 LOW
Regular or fall

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 Employees/Inform
Guard/sound the Obstructions on Body injuries due to slip, trip
Safety shoes / Hard hat / Awareness 4 2 2 4 LOW
nearest fire alarm passageways and fall
(siren/bell)

Musculoskeletal disorders due

Weight of FEX Proper lifting / Training 10 1 2 2 LOW
Run to/Get the to improper lifting/handling
nearest 20lbs FEX
NR Obstructions on Body injuries due to slip, trip
and put out the Safety shoes / Hard hat / Awareness 4 2 2 4 LOW
small fire passageways or fall
Flammable Training for the proper use of fire
Injury, death 10 5 2 10 MEDIUM
Gas /vapor extinguisher
Body injuries due to slips and
Slippery Surface Safety shoes / Awareness 2 2 2 4 LOW
Run to the falls
designated Crowded
NR Injury due to bumps Safety shoes/ hard hat 10 1 2 2 LOW
Emergency Emergency area
Area/Center Obstructions on Body injuries due to slips and
Safety shoes/ hard hat / Awareness 4 2 2 4 LOW
passageways falls
Vapor/Fumes
Chronic respiratory illnesses Gas Mask 2 2 2 4 LOW
Inhalation
Swift retrieval of Allergies, skin irritations, skin
  Dermatoxic Gloves / long-sleeve uniform 2 2 2 4 LOW
discharging hose cancer
Slippery surface Physical Injuries due to Falls,
Safety shoes / safety handrails 2 2 2 4 LOW
of TT platform Trips or Slips

Tank truck Retrieval of Tank

Improper
driver Truck chock NR Back pains Proper lifting procedure/orientation 2 1 2 2 LOW
handling /lifting
discharging blocks and FEX
at the UGT

Physical injury/Damage to Service Station speed limit at 5 - 10 kph /

Swift Moving TT 1 3 2 6 LOW
property due to bump guided & regulated by the Pump Attendant
maneuvering of
NR
truck to a safe
designated area Injury due to fall/trip when Use appropriate PPE (Safety Shoes, Hard
Height of truck 2 3 2 6 LOW
descending from the TT Hat)

Page | 13
 Moving tank Service Station speed limit at 5 - 10 kph /
Physical injury due to bump 10 3 2 6 LOW
Proceeding to the truck guided & regulated by the Pump Attendant
Assembly
NR
Area/Emergency Crowded
Control Centre Injury due to bumps Safety shoes / Awareness 10 1 2 2 LOW
Emergency area
Obstructions on Physical Injuries due to Falls,
Safety shoes / hard hat 10 2 2 4 LOW
passageways Trips and Slips
During Fire Slippery/ rough Body injuries due to slips and
Suppression Safety shoes / Hard hat / Awareness 10 2 2 4 LOW
Run to the Surface falls
Operation NR
assigned area Obstructed Body injuries due to slips, trips
Safety shoes / Hard hat / Awareness 10 2 2 4 LOW
pathways and falls

Weight of Musculoskeletal Disorders due

Team work / Awareness 4 1 2 2 LOW
equipment to improper lifting/handling
Lifting of
Firefighting NR Repetitive
equipment Motion / Work Musculoskeletal Disorders ergonomic tools 4 1 2 2 LOW
rest cycles
Forceful
Musculoskeletal Disorders Proper handling 4 1 2 2 LOW
Exertions
Evacuation Repetitive
Operation Motion / Work Musculoskeletal Disorders Proper posture of bending 4 1 2 2 LOW
rest cycles

Forceful Proper posture of bending / preventive

Musculoskeletal Disorders 4 1 2 2 LOW
Exertions maintenance

Weight of
Secure important Use of appropriate tools/ergonomics/ Team
equipment/ Musculoskeletal Disorders 4 1 2 2 LOW
documents / NR work
items
equipment
Obstructions on Physical Injuries due to Falls,
Use safety shoes and hard hat / Awareness 4 1 2 2 LOW
passageways Trips and Slips

Discomfort, heat stroke, heat

exhaustion, heat cramp, sun
Humidity Use of cotton clothing 4 1 2 2 LOW
stroke, heat rash, heat
fatigue, skin burns

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 Slippery Body injuries due to slips and
Safety shoes / Awareness 4 2 2 4 LOW
Surfaces falls
Shutdown Caught in the
Opening/Entry to Hand injury Gloves / Awareness 2 1 2 2 LOW
of Electrical Doors
Breaker the Electrical NR
Physical injury due to bump by
Panel Shed Moving door Safety shoes / hard hat 2 1 2 2 LOW
moving door
Electrical
Equipment
Failure/ Short
Circuits/
Switching-off of damaged wire/ Electrocution, Injuries, Shock, Regular check-up of electrical insulations
NR 2 3 2 6 LOW
Breaker worn-out wires/ burns, property damage and equipment
faulty
insulation/
loose electrical
wires

Control / direct / Depot speed limit at 5 - 10 kph / guided &

Traffic Moving vehicles Physical injury due to bump 2 3 2 6 LOW
orchestrate the regulated by the security guard
Control NR
crowd / vehicle
Operation
entries Uncontrolled Physical injury due to forceful
Guided and regulated by the SG 2 2 2 4 LOW
crowds entry in the depot
After the Repetitive
Emergency Motion / work Musculoskeletal Disorders Proper bending position / Team work 10 1 2 2 LOW
Response rest cycles
Activity Forceful
Exertions /
Musculoskeletal Disorders Proper bending position / Team work 10 1 2 2 LOW
uneven
workload
Housekeeping NR
Weight of
Musculoskeletal Disorders Proper lifting procedure/orientation 10 1 2 2 LOW
equipment
Protruding Physical injury due to sharp
Use safety shoes, gloves and hard hat 10 3 3 9 MEDIUM
materials/debris edges

Slippery Surface Slips, trips, falls Use safety shoes and hard hat 10 2 2 4 LOW
First Aid Responding / N Uneven ground Injury, bruises Use of safety shoes / warning signs / 2 2 2 4 LOW
Attending to the R pavement Awareness
victim

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 Slippery Safety shoes / housekeeping / warning
Injury, bruises 2 2 2 4 LOW
Flooring signs

Restricted
Physical Injuries due to bump Safety shoes / warning signs/ Awareness 2 2 2 4 LOW
Passageway
Slippery Injury due to slips, trips and
Use of safety shoes and warning signs 2 2 2 4 LOW
Flooring falls

Discomfort, heat stroke, heat

exhaustion, heat cramp, sun
Humidity Use of cotton clothing 2 1 2 2 LOW
stroke, heat rash, heat
fatigue, skin burns
Treating the N Improper
victim R
posture / Back injuries, muscular-
Proper lifting procedure/Ergonomics 2 1 2 2 LOW
Awkward skeletal disorders
position
Communicable
disease Serious Illness, Death Annual Physical Exam. 10 2 2 4 LOW
infection

Musculoskeletal disorders and

Poor, awkward illness (neck, shoulder, back Use of ergonomically designed office
2 1 2 2 LOW
posture disorder, mental fatigue, furniture & equipment,
headache, nausea)

Musculoskeletal disorders and

Transporting the N Repetitive Use of ergonomically designed office
illness (tendonitis, carpal 2 1 2 2 LOW
victim R motion furniture & equipment
tunnel syndrome)
Cramped work Mental Fatigue, Headache,
Housekeeping 4 1 2 2 LOW
space Nausea

Use of safety shoes / warning signs /

Slippery floor Slip, Trip, Fall - injury 4 1 2 2 LOW
Housekeeping

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 2.2 Medical Surveillance
The station 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: (X) CBC (X) Chest X-ray (X) Urinalysis (X) stool exam
b. Special: (X) Blood Chemistry (X) ECG ( ) others, please specify
c. Schedule of Annual medical examination: ( ) Q1 ( )Q2 ( )Q3 ( )Q4

Is random drug testing conducted? Yes (X) when_ANNUALLY No ( )

2.3 First-Aid, Health Care Medicines and Equipment Facilities

 How may treatment rooms/first aid rooms are existing in your company?
Treatment Room
 How many Clinics in the workplace? Not applicable
 What hospital (s) are you affiliated with? Input accredited hospitals and contact
person if applicable

3.0 And 4.0 - Health Programs for the promotion, prevention and control

This refers to: Drug-free Workplace in compliance to RA 9165, Human Immunodeficiency

Syndrome (HIV/AIDS) in compliance to (RA 8504) RA 11166, Tuberculosis in compliance to
EO 187-03, Hepatitis B in compliance to DOLE Advisory No. 05 Series of 2010, Mental
Health in compliance to RA 11036.

Kindly accomplish the policy template in Annex A.

(*you may attach individual policy statements)

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 Dealer or manager
Secretary _________________________________________________
Safety officer of the workplace
__________________________________________________
Member Name of at least one (1) worker, preferably a
union member, if organized

(All members of the HSC shall perform their duties and responsibilities by the OSH law and
its implementing guidelines.)

Page | 17
 (a) 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. – A SO2 shall establish an
OSH committee for medium risk establishment while an SO3 for high risk establishment. The
OSH committee shall be composed of the following:

Ex-officio chairperson ___________________________________________________

Name of Dealer or representative
Secretary ___________________________________________________
Safety officer of the workplace

Ex-officio members ___________________________________________________

Certified First-Aider
Members ___________________________________________________
Safety Officers representing the contractor or subcontractor, as
the case may be, and representative/s of the workers who shall
come from unions, if were organized, or elected workers through
a simple vote of majority, if they are unorganized

Safety and Health Committee Minutes/Reports submitted to DOLE (pls 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)

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

Juan De La Cruz Attach BOSH Certificate or Safety
Practitioner/Consultant Certificate

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

Page | 18
 Total number of Health Personnel & Facilities
Shift/Area/unit/ workers/areas Health Personnel (First- Facilities
Department aider, Nurse, Physician, (Treatment Room/
Dentist) Clinic/ Hospital)
Input hours of Shift / X First Aider Treatment Room
Treatment Room –
Sales Office

7.0 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)
(Please attach WEM results if applicable)

8.0 Conduct of Tool Box Meetings/ Safety Meetings if applicable

Conduct of Safety Meetings/Tool Box Date

Meetings
(Please attach Safety Meetings minutes)

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).

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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
(Please attach reportorial documents if
applicable)

10.0 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

Uniform X
Safety Shoes X

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 of 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 *(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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 Kindly attach dust control procedures, plans on temporary structures, permits applicable
for the operation of electrical, mechanical, communications systems and other
requirements

13.0 Workers Facilities Provided:

FACILITIES PROVIDED? REMARKS

YES NO
a. Adequate supply of drinking water X Attach picture of drinking
water supply
b. Adequate sanitary and washing X Attach picture of comfort
facilities rooms

c. Suitable living accommodation (if X Attach picture of service

master’s quarters if
applicable) applicable
d. Separate sanitary, washing and X Attach picture of service
master’s quarters if
sleeping facilities (if applicable) applicable
e. Lactation station (in consonance X Designate the Dealer’s
Office as Lactation Area.
with DOLE D.O. 143-15) Attach picture of dealer’s
office with the necessary
tools for lactation such
alcohol, tissue or curtain
to isolate the woman.
f. Ramps, railings, and the like X Attach picture of ramp for
PWD and CR Railings
g. Other workers’ welfare facilities as X
prescribed by OSHS and other
related issuances

14.0 Emergency and Disaster Preparedness:

14.1 Written Emergency and Disaster Program Yes_X___ No_____

14.2 Types and number of Drills conducted

Type of Drills (fire, Date Responsible

earthquake) person/position

15.0 Solid Waste Management System

Written Pollution Control Program: Yes: ___ No: _____
*attach solid waste management plan, pictures of trash bins with label

Name of Pollution Control Officer JUAN DE LA CRUZ

16.0 Compliance with Reportorial Government Requirements (refer to item 9.0)

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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)

(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
 Use your company’s policy regarding 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)

Php XXXXX_; 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 Input Cost

OSH trainings Input Cost

Safety Signages Input Cost

Machine Guards and related Input Cost

equipment

Medical examinations Input Cost

Medical supplies/medicines Input Cost

Others: Specify Input Cost

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ANNEX A:

WORKPLACE POLICY AND PROGRAM ON PROMOTING WORKERS HEALTH AND

ENSURING PREVENTION AND CONTROL OF HEALTH-RELATED ISSUES AND
ILLNESS
(NAME OF THE STATION) 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 station 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 station 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 station is committed to

ensuring workers’ health and providing a healthy and safe workplace.

______________________ ___________________________
Owner /Manager Employees’ Representative

DATE: ______________

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