Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Intramuros, Manila
Certificate Number: AJA15-0048
ESTABLISHMENT REPORT ON COVID-19
3 – 2020- March
(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)
NS GABASAN THE MUSIC HOUSE CENTER FOR THE ARTS
Floor/Bldg/No/Street/Subdivision*: 597 Bonifacio Corner Cervantes St.
Barangay/City/Municipality*: Brgy. Calaocan, San Jose City, Nueva Ecija
Kind of Business/Economic Music Learning Center/Tutorials
Activity/Principal Product:
Number of Workers*: Male: 6 Managerial Employees: 1
Female: 2 Supervisory: 1
Total: 8 Rank and File: 6
Total: 8
Date of Filing*: (mm/dd/yyyy) 03-30-
2020
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)
8 03-14-2020 OTH- Enhanced Community Quarantine
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)
8 03- 14-2020 OTH- Enhanced Community Quarantine
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
Employmen
No Name of Worker* Contact
(Last Name, First Name, Age* Sex* Home Address* Designation t Status Salary1
. M.I.) Number* (regular,
contractual, etc.)
Valdez, Brgy. Tulat,
0997577681
1 Ermelando Jr. 21 Male San Jose City, Administrator Regular 8,000/
2
M. Nueva Ecija Month
st
Brgy. Abar 1 ,
Damo, Michael 0906821970 General
2 41 Male San Jose City, Regular 6,000/
DG. 7 Services
Nueva Ecija Month
Brgy. Bantug,
Estolloso, Femal Science City of 0956016952 Music 114.00/
3 52 Contractual
Jasmin T. e Muñoz, Nueva 3 Teacher Hour
Ecija
Brgy. Agupalo
Weste, Lupao,
Soria, Lester 0965370644 Music 114.00/
4 Nueva Ecija Contractual
John S. 20 Male 1 Teacher Hour
(Relatives
House)
Brgy. Bagong
Andres,
Sikat, Science 0927558151 Music 114.00/
5 Melchor King III 22 Male Contractual
City of Muñoz, 0 Teacher Hour
J.
Nueva Ecija
Brgy.
Viernes, Rencie Calaocan, San 0955084820 Music 114.00/
6 28 Male Contractual
A. Jose City, 2 Teacher Hour
Nueva Ecija
Abar 1st, San
Lamson, Kim 0936333279 Music 114.00/
7 28 Male Jose City, Contractual
Kristoffer N. 7 Teacher Hour
Nueva Ecija
Curamen
Valdez, Leinwil Femal Subd. San 0932468099 Music 114.00/
8 23 Contractual
C. e Jose City, 0 Teacher Hour
Nueva Ecija
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Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Intramuros, Manila
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Certificate Number: AJA15-0048
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Indicate whether per hour, per day or per month
* Mandatory fields to be accomplished by the company representative for COVID-19 AMP applications.
