MGB Form No. 15-4

Republic of the PhilippinesDepartment of Environment and Natural Resources

MINE AND GEOSCIENCES BUREAUNorth Avenue, Diliman, Quezon City

MONTHLY EMPLOYER’S REPORT OF ACCIDENT OR ILLNESS

EMPLOYER :

1. Name of Operating Company: MINKONSTRAK ENGINEERING2. Address : POBLACION LUGA-IT, MISAMIS ORINETAL3. Name of Mine : 4. Location of Mine ___HOLCIM COMPOUND _____________________________5. No. of Employees : ___47____ Male : __4__ Female: 6. Name _____n/a______________________________________________________7. Chapa No : ______ ____________________________________________________8. Age: __n/a____ Civil Status : _____________ No. of Dependents: ___________9. Occupation when Injured : ___________ Experience at Occupation ______________10. Work Shift ____ 1st _X__ 2nd ____ 3rd Hrs. of Work/day :___8____ day/work11. Average weekly wage : _____2100____________12. Actual Duties at the Time of Accident : _____________________________________13. Length of Service prior to Accident or Illness ____________

ACCIDENT OR ILLNESS

14. Date of Accident/Illness : _____________________ Time : __________________15. Location of Accident/Illness : ___________________________16. Mining Method : _____________________ Beneficiation Process : ____________17. Type of Accident :

Personal Injury ( )Property Damage ( )

18. Detail description of Accident/Illness19. Was the injured performing his regular job at the time of accident/illness:

________________ if not, why _________________________________________

NATURE, EXTENT AND TREATMENT OF INJURY OR ILLNESS

20. Extent of Disability : _________ Fatal ___________ Permanent Total ____________

Permanent Partial ________ Temporary Total _______ Medical Treatment ________21. Nature of Injury or illness _______________ Parts of Body Injured _______________22. Date of disability started ________________ Date Returned to Work _____________23. Days Lost _____________________ Days Charged __________________24. Treatment __________________________________________________________

By whom __________________________________

MGB Form No. 15-4

CAUSE OF ACCIDENT

25. The Agency Involved ______________________________________26. The Agency Part Involved __________________________________27. Accident Type ___________________________________________28. Unsafe Mechanical or Physical Condition ______________________29. The unsafe act ____________________________________________30. Other contributing factors ___________________________________

PREVENTIVE MEASURES

31. Remediation (undertaken or recommended) : ______________________________32. Provision for Mechanical Guards; Personal Protective Equipment etc. are adequately met___________________________________________________________

RESPONSIBILITY

33. Was the Injured Negligent : ______________34. Was the Official or other Employees Responsible : _______________

MANPOWER

35. Compensation : __________________ Amount : ___________________36. Medical and Hospitalization : _____________________________________________37. Burial : _____________________________38. Time Lost on Day of injury ___________ hours ___________ mins. __________39. Time Lost on Subsequent Days due to treatment or follow ups _________________

hours _____________________ mins. _____________________40. Time on light work spent : ______________________ hrs. _________ mins._____

ACCIDENT COST

Machinery and Tools Damage

41. Damage to Machinery and Tools (Describe) _______________________________

____________________________________________________________________42. Cost of Repair or Replacement : _________________________________________43. Lost Production Time : _______________________ Cost :__________________44. Damage to Materials (Describe) ______________________________________________________________________________________________________________

Materials

45. Damage to Materials (Describe) : ________________________________________

MGB Form No. 15-4

46. Cost of Repair or Replacement :_________________________________________47. Lost Production Time : ________________________ Cost : __________________48. Damage to Equipment (Describe) : ______________________________________49. Cost of Repair and Replacement : _______________________________________50. Lost Production (downtime) : ____________________ Cost: _________________

DATE OF INVESTIGATION: __________________________DATE OF REPORT : __________________________

I HEREBY CERTIFY THAT THE FOREGOING INFORMATION ARE TRUE AND CORRECT TO THE BEST OF MY BELIEF.

May 31, 2016 Date

JEOFFREY A. ATILLO FRED VINCENT BALDOMERO

Safety Officer Project Engineer

NOTE: Copies to be sent to the Department of Labor and Employment and to the Mines and Geosciences Bureau’s Regional Offices, copy furnished - MGB-Central Office, by the operator/employers.