Annual Medical Report Form (DOLE - BWC - HSD - ) H-47-A)
Annual Medical Report Form (DOLE - BWC - HSD - ) H-47-A)
Annual Medical Report Form (DOLE - BWC - HSD - ) H-47-A)
Office Production/Shop
Ist Shift 2nd Shift 3rd Shift
Male: ________179_________ __179___ ___0____ __0_____
Female: _____ 21 __ _ 21 ___ ___0____ __0_____
Total: ____ _200__________ __200___ ___0____ __0_____
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b. Schedule of attendance in the workplace:
Workshift
Occupational Health Physician: ______________hrs./day __N/A_______
Occupational Health Dentist: ______________hrs./day __N/A_______
Occupational Health Practitioner: ____________hrs./day __ N/A_______
Occupational Health Nurse: ________________ hrs./day __ N/A_______
c. Schedule of attendance of full time first aider
(x) 1st workshift
( ) 2nd workshift
( ) 3rd workshift
d. The following occupational health personnel of this establishment have
undergone training in occupational health and safety/first aid:
( ) occupational health physician
( ) occupational health dentist
( ) occupational health nurse
( ) first-aider
( ) others, please specify: ______N/A_____________________________
9. Occupational Health Services:
a. The occupational health personnel of this establishment conducts regular
appraisal of the sanitation system in the workplace:
( ) yes (x) no
b. Number of workers who underwent the following medical examinations:
Physical Exams X-rays Urinalysis
1. Pre-placement ______________ _________ ____________
2. Periodic ______________ _________ ____________
3. Return-to-work ______________ _________ ____________
4. Transfer ______________ _________ ____________
5. Special ______________ _________ ____________
6. Separation ______________ _________ ____________
Stool Exam Blood Test ECG Others
1. Pre-placement _________ _________ ____ ____________
2. Periodic _________ _________ ____ ____________
3. Return-to-work _________ _________ ____ ____________
4. Transfer _________ _________ ____ ____________
5. Special _________ _________ ____ ____________
6. Separation _________ _________ ____ ____________
10. Report of Diseases
a. Number of consultations/treatments for the following diseases
Male Female Total No.
Of Cases
Skin:
( ) allergy __________ _________ ____________
( ) dermatomes __________ _________ ____________
( ) infections as folliculities __________ _________ ____________
abscess/paro nychia __________ _________ ____________
( ) Others __________ _________ ____________
Head:
( ) tension headache __________ _________ ____________
( ) others __________ _________ ____________
Eyes:
( ) error of refraction __________ ________ ____________
( ) bacteria/Viral __________ ________ ____________
conjunctivitis
( ) cataract __________ ________ ____________
( ) others __________ ________ ____________
Mouth & ENT:
( ) Gingivitis __________ ________ ____________
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Male Female Total No.
Of Cases
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___________ ( ) Sexually-Transmitted diseases_______
________ ___________
Male Female Total No.
Of Cases
( ) Hernia (Inguinal) __________ ________ ___________
(Femoral) __________ ________
___________
( ) Others __________ ________ ___________
Neuromuscular/Skeleal/Joints:
( ) Peripheral Neuritis __________ ________
___________
( ) Torticollis __________ ________ ___________
( ) Arthritis __________ ________ ___________
( ) Others __________ ________ ___________
Lymphatic and Circulatory
( ) Anemia __________ ________ ___________
( ) Leukemia __________ ________ ___________
( ) Cerebrovascular __________ ________ ___________
( ) Lymphadenitis __________ ________ ___________
( ) Lymphoma __________ ________ ___________
Infectious Diseases:
( ) Influenza __________ ________ ___________
( ) Typhoid/Paratyphoid Fever_________ ________ ___________
( ) Cholera __________ ________ ___________
( ) Measles __________ ________ ___________
( ) Mumps __________ ________ ___________
( ) Tetanus __________ ________ ___________
( ) Malaria __________ ________ ___________
( ) Schitosomiasis __________ ________ ___________
( ) Herpes Zoster __________ ________ ___________
( ) Chicken Pox __________ ________ ___________
( ) German Measles __________ ________ ___________
( ) Rabies __________ ________ ___________
( ) Others __________ ________ ___________
Diseases Due to Physical Environment:
a. Diseases Due to Noise and Vibration
( ) Deafness (noise induced) __________ ________ ___________
( ) White fingers disease __________ ________ ___________
( ) Musculo-skeletal disturbances _______ ________ ___________
( ) Fatigue __________ ________ ___________
b. Diseases Due to Temperature and
Humidity Abnormalities:
Hot temperature
( ) Heat strokes __________ ________ ___________
( ) Heat cramps __________ ________ ___________
( ) dehydration __________ _________ ___________
( ) neat exhaustion __________ _________ ___________
( ) others __________ _________ ___________
Cold Temperature
( ) Childblain __________ _________ ___________
( ) Frost bite __________ _________ ___________
( ) Immersion foot __________ _________ ___________
( ) General Hypothermia __________ _________ ___________
( ) Others __________ _________ ___________
c. Diseases due to Pressure Abnormalities:
( ) Decompression Sickness
( ) air embolism __________ _________ ___________
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( ) Bends Disease __________ _________ ___________
( ) Barotraumas __________ _________ ___________
( ) Hypoxia __________ _________ ___________
( ) Altitude sickness __________ _________ ___________
Male Female Total No. of
Cases
d. Diseases due to Radiation:
( ) cataracts __________ _________ ___________
( ) keratitis __________ _________ ___________
( ) burns __________ _________ ___________
( ) radiation-related cancer __________ _________ ___________
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Maternal and Child
Care Program
Family Planning Program
Mental Health Activities
Personal Health Maintenance
Physical Fitness Program: (Please Check)
Sports Activities ( ) Yes (x) No
Others (Please specify) ( ) Yes (x) No
16. Hazards in the workplace: (Please check give details of the substance)
Substance and/or Number of Workers
a. Chemical Hazards:
( ) dust (Ex. Silica dust) _________________________________
( ) liquids (Ex. Mercury) _________________________________
( ) mist/fumes/vapors _________________________________
(Ex. Mist from pint spraying)
( ) gas (Ex. CO, H2S) _________________________________
( ) others (Please Specify)
(Ex. Solvent) _______________ ____________
b. Physical Hazards
( ) Noise _______________ ____________
( ) temperature/humidity_____________ ____________
( ) pressure _______________ ____________
( ) illuminations _______________ ____________
( ) radiations/ultraviolet_____________ ____________
microwave
( ) vibrations _______________ ____________
( ) others (Please specify) ___________ ____________
c. Biological Hazards:
( ) Viral __________________ __________________
( ) Bacterial __________________ __________________
( ) Fungal __________________ __________________
( ) Parasitic __________________ __________________
( ) Others (please specify)________ __________________
d. Ergonomic Stress:
( ) Exhausting Physical___________ _________________
( ) Prolong Standing ___________ _________________
( ) Excessive Mental Effort _______ _________________
( ) Unfavorable Work Posture______ _________________
( ) Static/monotonous work________ _________________
( ) Others, specify_______________ _________________
Submitted by:
Noted by:
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Employer
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