Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Occupational Safety and Health Center
WORK ENVIRONMENT MEASUREMENT (WEM) REQUEST
Date of Request:
Company Name:
Company Address:
Head Office
Branch Office
Email address: ______________
Tel./Fax No:
______________
Requesting Personnel:
Position/Designation:
Type of Industry or Nature of Business:
Total Number of Workers:
Regular: _____ Contractual: _____
Accredited:
Yes
No
Name of Safety Officer:
Certificate of Compliance from DOLE: a) General Labor Laws
b) OSH Standards
Purpose of WEM Request
Yes
Yes
No
No
Workplace Improvement
ISO Compliance
Client/Customer Requirement
Others: Specify _____________________________
Company Status:
New Client
Regular Client
Date of last WEM: ____________ Conducted by: _________________
Improvements based on WEM recommendations:
(please attach page if space provided is not sufficient)
Parameters for measurement based on initial assessment of the Safety Officer per
work area (please check if applicable) :
A. Physical Hazards
Noise
Vibration
Illumination
Heat
B. Chemical Hazards
Dust
Heavy Metals
Organic Solvents
Acids
Others: Specify _____________________________________
C. Ventilation
General Ventilation
Local Exhaust Ventilation
This is to certify that the company agrees to pay all the expenses incurred during
coordination and other pre-WEM activities such as communication, consumables,
transportation expense, etc. if the company cancels the WEM on/ or 5 working days
before the scheduled WEM.
___________________________________
Name and Signature of Requesting Personnel
FM-ECD-WEM-21
Revision 00
Effectivity: January 2015
WORK ENVIRONMENT MEASUREMENT (WEM) REQUEST
Date of Request:
Company Name:
Company Address:
Head Office
Branch Office
Email address: ______________
Tel./Fax No:
______________
Requesting Personnel:
Position/Designation:
Type of Industry or Nature of Business:
Total Number of Workers:
Regular: _____ Contractual: _____
Accredited:
Yes
No
Name of Safety Officer:
Certificate of Compliance from DOLE: a) General Labor Laws
b) OSH Standards
Purpose of WEM Request
Yes
Yes
No
No
Workplace Improvement
ISO Compliance
Client/Customer Requirement
Others: Specify _____________________________
Company Status:
New Client
Regular Client
Date of last WEM: ____________ Conducted by: _________________
Improvements based on WEM recommendations:
(please attach page if space provided is not sufficient)
Parameters for measurement based on initial assessment of the Safety Officer per
work area (please check if applicable) :
A. Physical Hazards
Noise
Vibration
Illumination
Heat
B. Chemical Hazards
Dust
Heavy Metals
Organic Solvents
Acids
Others: Specify _____________________________________
C. Ventilation
General Ventilation
Local Exhaust Ventilation
This is to certify that the company agrees to pay all the expenses incurred during
coordination and other pre-WEM activities such as communication, consumables,
transportation expense, etc. if the company cancels the WEM on/ or 5 working days
before the scheduled WEM.
___________________________________
Name and Signature of Requesting Personnel
FM-ECD-WEM-21
Revision 00
Effectivity: January 2015
Note:
Please e-mail the signed and accomplished WEM Request Form to the following:
 oshcenter@oshc.dole.gov.ph
 oshc_dole@yahoo.com
 ecd_oshc@yahoo.com
or Faxed to: (632) 929-6030
and address to:
Ms. Ma. Teresita S. Cucueco, MD, CESO III
Executive Director
Occupational Safety and Health Center
Department of Labor and Employment