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Department of Labor and Employment: Republic of The Philippines Intramuros, Manila

This document is an establishment report on COVID-19 from the Department of Labor and Employment of the Philippines containing instructions and forms for companies to report flexible work arrangements or temporary closures due to the pandemic. Section A collects general establishment data. Section B summarizes affected workers, including the number covered and dates of flexible work arrangements or temporary closure. Page 2 lists personal details of affected workers such as name, age, address and salary. The report aims to provide assistance to companies and estimate dates of returning to normal operations.

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Christine Joyce Tenorio
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48 views2 pages

Department of Labor and Employment: Republic of The Philippines Intramuros, Manila

This document is an establishment report on COVID-19 from the Department of Labor and Employment of the Philippines containing instructions and forms for companies to report flexible work arrangements or temporary closures due to the pandemic. Section A collects general establishment data. Section B summarizes affected workers, including the number covered and dates of flexible work arrangements or temporary closure. Page 2 lists personal details of affected workers such as name, age, address and salary. The report aims to provide assistance to companies and estimate dates of returning to normal operations.

Uploaded by

Christine Joyce Tenorio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT


Intramuros, Manila

Certificate Number: AJA15-0048


ESTABLISHMENT REPORT ON COVID-19
_______________________________________
(Region-PO/FO-Year-Month-Count)
Instructions:
1. Accomplish this form in two copies when filing a notice of: a) Flexible Work Arrangement or b) Temporary 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 for COVID-19 Adjustment Measures Program
applications.
2. This form should be submitted to the DOLE Regional/Provincial/Field Office as soon as possible.
3. Page 1 should contain general information about the establishment and the number of workers affected.
4. Page 2 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.

A. Establishment Data
Name of Establishment*: (Please indicate registered name as reflected in the business permit)

Floor/Bldg/No/Street/Subdivision*:
Barangay/City/Municipality*:
Kind of Business/Economic
Activity/Principal Product:
Number of Workers*: Male: Managerial Employees:
Female: Supervisory:
Total: Rank and File:
Total:
Date of Filing*: (mm/dd/yyyy)

B. Summary of Affected Workers due to


B.1 Flexible Work Arrangement*
Type of Flexible Work Arrangement
No. of Workers Effectivity Date
to be Implemented
Covered/Affected (mm/dd/yyyy)
(Use code below, select only one)

Codes for Flexible Work Arrangement Scheme:


 RW - Reduction of Workdays  FL - Forced Leave
 RE - Rotation of Employees  OTH - Others (Specify) ____________

B.2 Temporary Closure*


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

Codes for Main Reason for Temporary Closure:


 LM - Lack of Market/Slump in Demand  I - Infection (COVID-19)
 LRM - Lack of Raw Materials  OTH - Others (Specify) ____________

CERTIFICATION
This is to certify as to the accuracy of the data provided in this report.
Name and Signature of Owner/Company Representative*:

Designation: Fax No.:

Contact No.: Email Address:

FOR DOLE (Regional/Provincial/Field Office) USE ONLY:


Updates/Remarks, if any:
Received/Verified by: a) Provision of assistance (please specify)
________________________________________________
b) Estimated date of resumption of normal business operations:
______________________________________ ________________________________________________
Name and Signature of DOLE Representative c) Others (please specify)
________________________________________________
Name and Signature of DOLE Representative:
Date: ______________

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

Certificate Number: AJA15-0048

LIST OF AFFECTED WORKERS DUE TO COVID-19

Instructions: If necessary, use additional sheets following the same format.

Profile of Affected Workers

Employment
Name of Worker* Contact Status
No. Age* Sex* Home Address* Designation Salary1
(Last Name, First Name, M.I.) Number* (regular,
contractual, etc.)
1

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30
1
Indicate whether per hour, per day or per month
* Mandatory fields to be accomplished by the company representative for COVID-19 AMP applications.

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