2009 / Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
______Caraga Region______
(Field Office/Regional Office) / Page 1 of _ pages
Instructions:
- Accomplish this form in two copies when filing a notice of displacement/adoption of flexible work arrangements. The report is considered as duly filed when the complete list of workers affected is made part of the submission.
- This form should be submitted to the DOLE Field Office 30 calendar days prior to the effectivity of displacements/adoption of flexible work arrangements.
- Page 1 should contain general information about the establishment and the number of workers affected.
- Page 2 should enumerate the names of workers affected, their addresses and contact numbers and type of displacement/flexible work arrangements.
- Total number of workers listed should equal the total number of workers affected asreported in this page.
ESTABLISHMENT EMPLOYMENT REPORT
A. Establishment Data:
Name of Establishment ______
Floor/Bldg./No./Street/Subdivision ______
______
Barangay/City/Municipality ______
Zip Code/Province ______GEOCODE: l l l l l l l l l l
Main Economic Activity (Specify product/goods/services):______
______PSIC: l l l l l l l
Total Employment: / No. of Female Workers:
Date of Filing of RKS Form 5 (mm/dd/yyyy): l l l l l l l l l
1. Establishment Status:(Please check applicable status)
[ ] Permanent Closure [ ] Temporary Closure
[ ] Reduction of Workforce [ ] Flexible Work Arrangements
2. Main Reason for Shutdown/Retrenchment of Workers (Use code below, select only one): ______
3. Is the closure/reduction of workforce/flexible work arrangements a consequence of:
[ ] Global Crisis [ ] Others (specify)______
B. Workers Affected by Displacements/Flexible Work Arrangements
Indicator / No. of Workers Affected / Effectivity Date
From
(mm/dd/yyyy) / To
(mm/dd/yyyy)
(1) / (2) / (3) / (4)
1. Permanent Terminations
2. Temporary Layoffs
3. Flexible Work Arrangements
3.1 Rotation of Workers
3.2 Reduced Workhours/Workdays
3.3 Forced Leave
Codes for Main Reason for Shutdown/Retrenchment of Workers:
Economic Reasons / Non-Economic Reasons
LMCancellation of orders/ Lack of market/ Slump in demand
LCLack of capital
HCPHigh cost of production
RRedundancy
CMMChange in management
/merger
RDSCompany reorganization/
Downsizing / CICompetition from imported products
UCPUncompetitive price of product
MRIncrease in minimum wage rate
LRMLack of raw materials
PDPeso devaluation/ appreciation
OTHOthers (Specify)______
______ / PCProject Completion
AWOLAbsence without Leave
SMSerious Misconduct
GHNGross Habitual Neglect
CCOCommission of a Crime or Offense
FUDFraud / NCLNatural Calamities (fire, typhoon, etc.)
LLDACeased and Desist Order
NRMRepair/General Maintenance
INVInventory
FDLForced Leave
RESResigned
RETRetirement
OTHSOthers (Specify)______
______
CERTIFICATION
Name/Signature of Owner/Company Representative:Position: / Fax No.:
Tel. No.: / E-mail Address:
This is to certify as to the accuracy of thedata provided in this report.
RKS Form 52009 / Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
______Caraga Region______
(Field Office/Regional Office) / Page 2 of _ pages
Instruction: Use additional sheets if necessary following the same format.
LIST OF AFFECTED WORKERS BY DISPLACEMENTS/
FLEXIBLE WORK ARRANGEMENTS
Name of Establishment ______
Floor/Bldg./No./Street/Subdivision ______
______
Barangay/City/Municipality ______
Zip Code/Province ______GEOCODE: l l l l l l l l l l
Date of Filing of RKS Form 5 (mm/dd/yyyy): l l l l l l l l l
No. / Name of Worker
(Last Name, First Name, M. I.) / Address / Contact Number/s / Type of Displacements/
Flexible Work Arrangements
(Use code below)
(1) / (2) / (3) / (4) / (5)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
Codes for Type of Displacements/Flexible Work Arrangements:
1- Permanent Termination / 3 - Rotation of Workers / 5 – Forced Leave
2 - Temporary Layoff / 4 - Reduced Workhours/Workdays