Republic of the Philippines
Department of Labor and Employment
National Capital Region
ANNUAL MEDICAL REPORT FORM
For Period January 1, 2022 to December 31, 2022
1. Name of Establishment: CYANCLAY INC
2. Address: 909 HIGHSTREET TOWER SOUTH, BGC TAGUIG
3. Name of Owner/ Manager: SIMON YANG
4. Nature of Business & Product/ Service (Ex. Manufacturing – textile)
CONSTRUCTION PROJECT MANAGEMENT
5. Total Number of Employee: 48 Number of Shift: 1
6. Number Distribution of Employee as to nature/workplace, sex & workship:
office
Male :___________
Female:__________
Total:___________
Product/Shop
2nd Shift
______________
______________
______________
1st Shift
43
5
48
3rd Shift
____________
____________
____________
7. Preventive Occupational Health Service: (Check or Cross)
a. Occupational health service is organized / provided by:
( X) the establishment / undertaking
( ) government authority / institution
( ) other bodies / group / institution ( specify )__________________________
____________________________________________________________
b. Occupational health services as described under number 7a above, is organized /
provided as a service :
( X) solely for the workers of the establishment /
undertakings ( ) common to a number of establishment /
undertakings
1
c. The employer engages the services of :
( ) Occupational health practitioner
Name: ______________________________________________________
Address: ____________________________________________________
( ) Occupational health physician
Name: ______________________________________________________
Address: ____________________________________________________
( ) Occupational health dentist
Name: ______________________________________________________
Address: ____________________________________________________
( ) Occupational health nurse
Name: ______________________________________________________
Address: ____________________________________________________
d. The occupational health physician/practitioner/nurse/personnel conducts an
inspection of the work place:
( ) once every month
( ) once every two (2) months
( ) once every three (3) months
( ) once every six (6) months
( ) other details:ANNUALLY
8. Emergency Occupational Health Services:
a. The employer provides a treatment room/medical clinic in the work place with
medicines and facilities
( ) Yes _________________
( X) No __________________
( ) others, please specify __________________________________________
____________________________________________________________
b. Schedule of attendance in the work place:
Occupational health physician
Occupational health dentist
:________
:________
c. Schedule of attendance of full time first aider
( ) 1st work shift
( )2nd work shift
( ) 3rd work shift
2
Work shift
hrs./day___________
hrs/day ___________
d. The following occupational health personal of this establishment have under
gone training in occupation health and safety/first aid :
( ) Occupational health physician
( ) Occupation health dentist
( ) Occupation health nurse
( X) first - aider
( ) Others, please specify___________________________________________
____________________________________________________________
9. Occupational Health Services
a. The occupational health personnel of this establishment regular appraisal of the
sanitation system in the workplace:
( X) Yes
( ) No
b. Number of workers who underwent the following medical examinations:
1.
2.
3.
4.
5.
6.
1.
2.
3.
4.
5.
6.
Pre-placement
Periodic
Return-to –work
Transfer
Special
Separation
Physical Exam
____________
____________
____________
____________
____________
____________
Pre-placement
Periodic
Return-to-work
Transfer
Special
Separation
Stool
Exam
______
______
______
______
______
______
-3-
X-rays
________
________
________
________
________
________
Blood
Test
______
______
______
______
______
______
Urinalysis
___________
____________
____________
____________
____________
____________
ECG
Others
______
______
______
______
______
______
______
______
______
______
______
______
10. Report of Diseases
a. Number of consultations/treatments for the following diseases:
Male
Female
Total No.
Of Cases
______
______
_______
_______
0
0
0
______
______
_______
_______
0
0
______
______
_______
_______
0
0
______
_______
0
______
______
______
_______
_______
_______
0
0
0
______
_______
0
______
_______
0
______
______
_______
_______
0
0
______
______
______
______
_______
_______
_______
_______
0
0
0
0
Skin:
( ) Allergy
( ) Dermatoses
( ) Infection as
folliculitis
abscess/paronychia
( ) Others
Head:
( ) Tension/headache
( ) Others
Eyes:
( ) Error of
refraction
( ) Bacterial/Viral
conjunctivities
( ) Cataract
( ) Others
Mouth & ENT:
( ) Gingivitis
( ) Herpes Labiales/
nasalis
( ) Otitis Media
Externa
( ) Deafness
( ) Meniere”s Syndrome
/Vertigo
( ) Rhinitis/Colds
( ) Nasal Polyps
( ) Sinusitis
( ) Tonsilio
4
pharyngitis
( ) Laryngitis
( ) Others
______
______
______
0
0
0
_______
_______
_______
Respiratory:
(
(
(
(
(
(
)
)
)
)
)
)
Bronchitis
Bronchial/Asthma
Pneumonia
Tuberculosis
Pneumoconiosis
Others
______
______
______
______
______
______
_______
_______
_______
_______
_______
_______
______
______
______
_______
_______
_______
______
_______
______
______
_______
_______
______
______
_______
_______
______
______
_______
_______
______
_______
0
0
0
0
0
Heart and Blood Vessel:
(
(
(
(
)
)
)
)
Hypertension
Hypotension
Angina Pectoris
Myocardial
Infraction
( ) Vascular
disturbances in
extremities due
to continuous
vibration
( ) Others
0
0
0
0
0
0
Gastrointestinal:
( ) Casroenteritis/
Diarrhea
( ) Amoebiasis
( ) Gastritis/
Hyperacidity
( ) Appendicitis
( ) Infectious
Hepatitis
5
0
0
0
0
0
0
0
( ) Liver Cirrhosis
( ) Hepatic Abscess
( ) Cancer (Hepatic/
Gastric)
( ) Ulcer
( ) Others
______
______
_______
_______
0
0
______
______
______
_______
_______
_______
0
0
0
______
______
_____
_____
_______
_______
_______
_______
0
0
0
0
_____
_______
0
_____
_______
0
_____
_____
_______
_______
0
0
_____
_____
_______
_______
0
0
______
_______
0
Male
Female
______
______
______
______
______
______
________
________
________
________
________
________
Total No.
Of Cases
0
0
0
0
0
0
Genito Urinary:
( ) Urinary Tract
infection
( ) Stones
( ) Cancer
( ) Others
Reproductive:
( ) Dysmenorrhea
( ) Isfection
(Cervicitive)
(Vaginitis)
( ) Abortion
(Spontaneus)
(threatened)
( ) Hyperremesis
Gravidarum
( ) Uterine Tumors
( ) Cervical Polyp/
Cancer
12. Immunization Program (Indicate number immunized)
Nature
Tetanus Toxoid Injection
Tetanus Antioxin Injection
Tetanus Globulin Injection
Hepatitis B Vaccine
Rabies Vaccine
Others (Please Specify)
6
13. Keeping of Medical Records of Workers (Please Check)
( X)
Done
( )
Not Done
14. Health Education and Counseling by Health and Safety Personnel: (Please Check one
or more)
(X)
done individual as each worker comes to the clinic for
consultation. ( )
done in organized group discussions/seminars.
( )
done with the use of visual displays and/or promotional materials,
leaflets, etc.
15. Other Health Programs (Please Check)
Kinds of Program
Seminars
Nutrition Program
Material and Child Care Program
Family Planning Program
Mental Health Activities
Personal Health Maintenance
(
(
(
(
(
)
)
)
)
)
Use of Visual
id/Materials
( )
( )
( )
( )
( )
Counseling
(
(
(
(
(
)
)
)
)
)
Physical Fitness Program: (Please Check)
Sport Activities
Others (Please Check)
( ) Yes
( ) Yes
(X )
(X)
No
No
16. Hazard in the workplace : (Please check and give details of the substance)
Substance and/or
Number of workers
sources
a. Chemical Hazard:
b.
( ) Dust (Ex. Silica dust)
( ) Liquid (Ex. Mercury)
( ) Mist/fumes/vapors
(Ex. mist from paint spraying)
( ) Gas (Ex. CO, H2S)
( ) Others (please specify)
(Ex. solvents)
_____________
_____________
_____________
_____________
_____________
7
exposed
0
0
0
0
Physical Hazards
( X ) Noise
( ) Temperature/humidity
( ) Pressure
( ) Illumination
( ) Radiation/ultraviolet/microwave
( ) Vibration
( ) Others (Please specify)
c. Biological hazard:
(
(
(
(
(
) Viral
) Bacterial
) Fungal
) Parasitic
) Others, specify
_____________
_____________
_____________
_____________
_____________
_________________
_________________
_________________
_________________
_________________
_____________
_____________
_____________
_____________
_____________
_____________
_________________
__________________
__________________
__________________
__________________
__________________
d. Ergonomic Stress:
(
(
(
(
(
(
) Exhausting physical work
) Prolonged standing
X) Low back pain
) Unfavorable work posture
) Static/monotonous work
) Others, specify
Submitted by:
ROLAND MAGO
EHS Personnel
__________________
Date
Noted by:
SIMON YANG
Employer