DEPARTMENT OF LABOR AND EMPLOYMENT



RKS Form 5 of2020323850-889000042697403048000Republic of the PhilippinesDEPARTMENT OF LABOR AND EMPLOYMENT______________________________________Region-PO/FO-Year-Month-Count428752014605Certificate Number: AJA15-004800Certificate Number: AJA15-0048(ex. NCR-MFO-2020-05-001)Page 1 of 3Instructions:Accomplish this form when filing a notice of: a) Flexible Work Arrangement/Alternative Work Scheme; b) Temporary Closure; c) Retrenchment or Reduction of Workforce; or d) Permanent 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.This form should be submitted to the DOLE Provincial/Field Office as soon as possible in the case of adoption of flexible work arrangement or temporary closure. For establishments that will retrench or permanently close, the form should be submitted 30 days prior to the effectivity of termination.Page 1 should contain general information about the establishment and the number of workers affected.Page 3 should enumerate the names of workers affected, their addresses and contact numbers, and other information stated therein.Total number of workers listed should equal the total number of workers affected as reported in this page.ESTABLISHMENT REPORTFLEXIBLE WORK ARRANGEMENT (FWA) / ALTERNATIVE WORK SCHEME (AWS)TEMPORARY CLOSURERETRENCHMENT/REDUCTION OF WORKFORCEPERMANENT CLOSUREDate of Filing (mm-dd-yyyy): mm-dd-yyyyESTABLISHMENT INFORMATION*Name of Establishment:*Floor/Bldg/No/Street/Subdivision:*Barangay/City/Municipality:Geo Code:Kind of Business/Economic Activity/Principal Product::PSIC Code:*Company TIN:*Company SSS Number:*Number of WorkersMale:Managerial Employees:Female:Supervisory:Total:Rank-and-File:Total:SUMMARY OF AFFECTED EMPLOYEES DUE TOFlexible Work Arrangement / Alternative Work Scheme*No. of Workers Covered/AffectedPeriod of Adoption of FWA / AWSType of FWA/AWS to be Implemented(Use code below, select only one)Primary Reason of Adoption of FWA/AWS(Use code below, select only one)Start(mm/dd/yyyy)End(mm/dd/yyyy)Codes for Types of FWAs/AWSTOE-Transfer of employees to another branch or outlet of the same employerROW-Rotation of workersFCL-Forced leaveAOE- Assignment of employees to other function or position in the same or other branch or outlet of the same employerBTS-Broken-time scheduleCWW-Compressed Work WeekRWD-Reduction of workdays per weekTWA-Telecommuting Work Arrangement RWH-Reduction of workhours per dayOTH-Others (please specify)JR-Job rotation alternately providing employees with work within the workweek or within the monthPCE-Partial closure of establishment where some unit or departments of the establishment are continued while other units or department are closedCodes for Primary Reason for Adoption of FWA/AWS:Economic ReasonsNon-Economic ReasonsCI-Competition from ImportsLRM-Lack of raw materialsINV-Inventory CMM-Change in management/mergerMR-Increase in minimum wage rateNMC-Natural or man-made calamityFL-Financial lossesPD-Peso depreciationPC-Project completionGR-Government regulationUPP-Uncompetitive price of productsRGM-Repair or general maintenanceHCP-High cost of productionOTH-Others (please specify):WSO-Work stoppage order/ cease andLC-Lack of capitaldesist orderLM-Lack of market/ slump in demand/ OTH-Others (please specify):cancellation of ordersRKS Form 5 of2020323850-889000042697403048000Republic of the PhilippinesDEPARTMENT OF LABOR AND EMPLOYMENT______________________________________Region-PO/FO-Year-Month-Count428752014605Certificate Number: AJA15-004800Certificate Number: AJA15-0048(ex. NCR-MFO-2020-05-001)Page 2 of 3Temporary Closure*No. of Workers Covered/AffectedPeriod of Temporary ClosurePrimary Reason of Temporary Closure(Use code below, select only one)Start(mm/dd/yyyy)End(mm/dd/yyyy)Retrenchment/Reduction of Workforce*No. of Workers Covered/AffectedEffectivity Date(mm/dd/yyyy)Primary Reason of Retrenchment(Use code below, select only one)Permanent Closure*No. of Workers Covered/AffectedEffectivity Date of Termination(mm/dd/yyyy)Primary Reason of Permanent Closure(Use code below, select only one)Codes for Primary Reason Temporary Closure (B.2)/Retrenchment (B.3) / Permanent Closure (B.4):Economic ReasonsNon-Economic ReasonsCI-Competition from ImportsMR-Increase in minimum wage rateAWOL-Absence without leaveCMM-Change in management/mergerPD-Peso depreciationCCO-Commission of a crime or offenseFL-Financial lossesR-RedundancyFWBT-Fraud or willful breach of trustCOE-Closure or cessation of operation of anRDS-Reorganization/downsizingGHN-Gross and habitual neglect of dutyestablishment not due to serious losses RPL-Retrenchment to prevent lossesINV-Inventory of financial reversesOTH-Others (please specify):IR-Impossible reinstatementEDC-Employee suffering from a disease not NMC-Natural or man-made calamitycurable within the period of six (6) PC-Project completionmonthsRES-ResignationGD-Government decisionRET-RetirementHCP-High cost of productionRGM-Repair or general maintenanceLC-Lack of capitalSMWD-Serious misconduct or willful LRM-Lack of raw materialsdisobedienceLM-Lack of market/ slump in demand/ WSO-Work stoppage order/ cease andcancellation of ordersdesist orderLSA-Lack of service assignmentOTH-Others (please specify):LSD-Installation of labor-saving devicesAGREEMENT ON ADOPTION OF FWA/AWSThis is to certify as to the following:That I am the employees’ representative;That the data provided in Item B.1 Summary of Affected Employees - Flexible Work Arrangement/Alternative Work Scheme are accurate;That a consultation with the workers was undertaken prior to the adoption of FWA; andAttached is a copy of the Agreement.Signature Over Printed Name of Employees’ Representative and DateDesignation:Mobile No.:Telephone No.:E-mail Address:CERTIFICATIONThis is to certify as to the accuracy of the data provided in this report.Signature Over Printed Name of Owner or Company Representative and DateDesignation:Mobile No.:Telephone No.:E-mail Address:10260330167005Page 3 of 300Page 3 of 321145503810008459470-571500Republic of the PhilippinesDEPARTMENT OF LABOR AND EMPLOYMENT Intramuros, Manila842264066675Certificate Number: AJA15-004800Certificate Number: AJA15-0048LIST OF AFFECTED WORKERSInstruction: If necessary, use additional sheets following the same format. CONSENT NOTICE: By accomplishing this form, you agree that the information submitted shall be used solely for purposes of monitoring and planning. We may likewise disclose your personal information to the extent that we are required to do so by the Data Privacy Act of 2012. As a general rule, we may only keep your information until such time that we have attained the purpose by which we collect them. Under the foregoing circumstances and to the extent permissible by applicable law, you agree not to take any action against the DOLE for the disclosure and retention of your information. No.Name of Worker*Birthday*(dd/mm/yyyy)Sex*(F/M)Home Address*Contact No*Email Address*Designation*Employment Status*(regular, contractual, etc.)Monthly Salary (in Peso)*Adopted Work Arrangement*Last NameFirst NameMiddle NameHouse NumberStreetBrgy.City/MunicipalityProvince4,000-10,00010,001-16,00016,001-22,00022,001-28,00028,001 and above12345678910111213141516 *Mandatory fields to be accomplished by the company representative *a ................
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