Download Annual Medical Report Form

DOLE/BWC/HSD/OH-47-A
Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Bureau of Working Conditions
ANNUAL MEDICAL REPORT FORM
For Period January 01,_______ to December 31,_______
1.
2.
3.
4.
5.
6.
Name of Establishment: ______________________________________________
Address:__________________________________________________________
Name of Owner/Manager: ____________________________________________
Nature of Business and Products/Services (Ex. Manufacturing, Textile
_________________________________________________________________
Total Numbers of Employees:____________ Number of Shifts:______________
Number Distribution of Employees as to nature/workplace, sex and work shift:
Office
Male: ____________________
Female: ___________________
Total: ____________________
7.
Production/Shop
Ist Shift
2nd Shift
________
________
________
________
________
________
3rd Shift
________
________
________
Preventive Occupational Health Services: (Check or Cross)
a
Occupational Health Services is organized/provided by:
( ) The establishment /undertaking
( ) Government authority institution
( ) Other bodies/groups/institution (specify) ________________________
b
Occupational health services as described under number 7a above is
organizes/provided as a services:
( ) Solely for the workers of the establishment/undertaking
( ) Common to any number of establishment/undertakings _____________
c
The employer engages the service of:
( ) Occupational health practitioner
Name & Address: _____________________________________________
( ) Occupational Health physician
Name & Address: _____________________________________________
( ) Occupational Health dentist
Name & Address: _____________________________________________
( ) Occupational health nurse
Name & Address: _____________________________________________
d.
8.
The occupational health physician/practitioner/nurse/personnel conduct an
inspection of the workplace:
( ) Once every month
( ) Once every three (3) months
( ) Once every two (2) months
( ) Once every six (6) months
( ) Other details ______________________________________________
Emergency Occupational Health Services:
a.
The employer provides a treatment room/medial clinic in the workplace
with medicines and facilities:
( ) yes___________
( ) No
( ) others, please specify _______________________________________
1
b.
9.
10.
Schedule of attendance in the workplace:
Workshift
Occupational Health Physician: ______________hrs./day _____________
Occupational Health Dentist: ______________hrs./day _____________
Occupational Health Practitioner: ____________hrs./day _____________
Occupational Health Nurse: ________________ hrs./day _____________
c.
Schedule of attendance of full time first aider
( ) 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: ______________________________________
Occupational Health Services:
a.
The occupational health personnel of this establishment conducts regular
appraisal of the sanitation system in the workplace:
( ) yes
( ) 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
_________
_________
____ ____________
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
__________ ________
____________
2
Male
(
(
(
(
) Herpes liables/nasal’s
__________
) Otitis/Media External
__________
) Deafness
__________
) Meniere’s syndrome
Vertigo
__________
( ) Rhinitis/Cold
__________
( ) Nasal Polyps
__________
( ) Sinusitis
__________
( ) Tonsillopharynngitis
__________
( ) Laryngitis
__________
( ) Others
__________
Respiratory:
( ) Bronchitis
__________
( ) Pneumonia
__________
( ) Tuberculosis
__________
( ) Pneumoconiosis
__________
( ) Others
__________
Hearth & Blood Vessels:
( ) Hypertension
__________
( ) Hypertension
__________
( ) Angina Pectoris
__________
( ) Myocardial Infarction
__________
( ) Vascular Disturbance in
extremities due to continues_________
Vibration
( ) Others
__________
Gastrointestinal:
( ) Gastroenteritis
__________
( ) Amoebiasis
__________
( ) Gastritis/Hyperacidity
__________
( ) Appendicitis
__________
( ) Infectious/Hepatitis
__________
( ) Liver Cirrhosis
__________
( ) Hepatic Abscess
__________
( ) Cancer (Hepatic/Gastric) __________
( ) Ulcer
__________
( ) Others
__________
Genito Urinary:
( ) Urinary Tract Infection __________
( ) Stones
__________
( ) Cancer
__________
( ) Others
__________
Reproductive
( ) Dysmenorrhea
__________
( ) Infection (Cervicitis)
__________
(Vaginitis)
__________
( ) Abortion (Spontaneous) __________
(threatened) __________
( ) Hyperemesis Gravidarum __________
( ) Uterine Tumors
__________
( ) Cervical Polyp/Cancer
__________
( ) Ovarian Cyst/Tumors
__________
( ) Sexually-Transmitted diseases_______
Female
Total No.
Of Cases
________
________
________
____________
____________
____________
________
________
________
________
________
________
________
____________
____________
____________
____________
____________
____________
____________
________
________
________
________
________
____________
____________
____________
____________
____________
________
________
________
________
____________
____________
____________
____________
________
____________
________
____________
________
________
________
________
________
________
________
________
________
________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
________
________
________
________
____________
____________
____________
_______
________
________
________
________
________
________
________
________
________
________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
3
Male
( ) 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
__________
( ) Bends Disease
__________
( ) Barotraumas
__________
( ) Hypoxia
__________
( ) Altitude sickness
__________
Female
________
________
________
Total No.
Of Cases
___________
___________
___________
________
________
________
________
___________
___________
___________
___________
________
________
________
________
________
___________
___________
___________
___________
___________
________
________
________
________
________
________
________
________
________
________
________
________
________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
________
________
________
________
___________
___________
___________
___________
________
________
_________
_________
_________
___________
___________
___________
___________
___________
_________
_________
_________
_________
_________
___________
___________
___________
___________
___________
_________
_________
_________
_________
_________
___________
___________
___________
___________
___________
4
d.
Diseases due to Radiation:
( ) cataracts
( ) keratitis
( ) burns
( ) radiation-related cancer
TOTAL NUMBER
11.
12.
Male
Female
Total No. of
Cases
__________
__________
__________
__________
_________
_________
_________
_________
___________
___________
___________
___________
__________
_________
___________
Report of Occupational Accidents/injuries
Nature
Male
Female
Confusion, bruises,
Hematoma
_________
_________
Abrasions
_________
_________
Cuts, lacerations,
Punctures
_________
_________
Concussion
_________
_________
Avulsion
_________
_________
Amputation, loss of
Body parts
_________
_________
Crushing
_________
_________
Injuries Spinal
_________
_________
Injuries Cranial
_________
_________
Injuries Sprains
_________
_________
Dislocation/fractures _________
_________
Burns
_________
_________
Number of Case
_______________
_______________
_______________
______________
______________
______________
______________
_____________
_____________
_____________
_____________
_____________
Immunization Program (indicate number immunized)
Tetanus Toxiod Injection
________
________
Tetanus Antitoxin Injection
________
________
Tetanus Globulin Injection
________
________
Hepatitis B Vaccine
________
________
Rabies Vaccine
________
________
Others (please specify)
________
________
___________
___________
___________
___________
___________
___________
13.
Keeping of Medical Records of Workers (Please Check)
( ) done
( ) not done
14.
Health Education and counseling by health and Safety Personnel:
(Please check done or more)
( ) done individual as each worker comes to the clinic for consultation.
( ) done in organized group discussions/seminars. Health Center
( ) done with the use of visual display and/or promotional material,
leaflets, etc.
15.
Other Health Programs (Please Check)
Kinds of Program
Seminar
Use of Visual
Aid/Material
Counseling
Nutrition Program
Maternal and Child
Care Program
Family Planning Program
Mental Health Activities
Personal Health Maintenance
5
Physical Fitness Program: (Please Check)
Sports Activities
( ) Yes
Others (Please specify)
( ) Yes
16.
( ) No
( ) No
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.
c.
d.
Physical Hazards
( ) Noise
_______________
( ) temperature/humidity_____________
( ) pressure
_______________
( ) illuminations
_______________
( ) radiations/ultraviolet_____________
microwave
( ) vibrations
_______________
( ) others (Please specify) ___________
____________
____________
____________
____________
____________
____________
____________
Biological Hazards:
( ) Viral
__________________
( ) Bacterial __________________
( ) Fungal
__________________
( ) Parasitic __________________
( ) Others (please specify)________
__________________
__________________
__________________
__________________
__________________
Ergonomic Stress:
( ) Exhausting Physical___________
( ) Prolong Standing ___________
( ) Excessive Mental Effort _______
( ) Unfavorable Work Posture______
( ) Static/monotonous work________
( ) Others, specify_______________
_________________
_________________
_________________
_________________
_________________
_________________
Submitted by:
______________________________
Medical/Personnel/Title
_______________________
Date
Noted by:
_______________________________
Employer
Fn:\AMR-FORM.DOC
CHE 012904
6