Form B.

Child Personal & Work Profile Form

Republic of the Philippines DEPARTMENT OF LABOR AND EMPLOYMENT Child Personal & Work Profile Form

Name of Establishment Name of Child

Date of Birth Current Age

Address Address & Tel. No.

Birth Certificate Available? Yes No

Inspection Authority No.

Sex Male Female

Age Started Working (with any type of work) Educational Attainment (Grade/Year Last Attended)

Occupation/Job Title Name of Father Name of Guardian Form of Labor/Work Conditions prostitution pornography obscene or lewd shows imminent danger (exposure to a condition or practice that could be reasonably expected to cause death or serious physical harm) slavery or similar practices, such as sale or trafficking of children, debt bondage, serfdom, forced labor, recruitment of children for armed conflict production and trafficking of dangerous drugs and volatile substances other illegal or illicit activities public entertainment or information directly under sole responsibility of parents others

Name of Mother Hazardous or likely to be harmful to the health, safety, or morals of children Debases, degrades or demeans the intrinsic worth and dignity of the child as a human being Exposes the child to physical, emotional or sexual abuse, or is found to be highly stressful psychologically or may prejudice morals Performed underground, under water, or at dangerous heights Involves the use of dangerous machinery, equipment and tools, such as power-driven or explosive powder-actuated tools Exposes the child to physical danger such as, but not limited to the dangerous feats of balancing, physical strength or contortion, or which requires the manual transport of heavy loads Performed in an unhealthy environment exposing the child to hazardous working conditions, elements, substances, so-agents or processes involving ionizing, radiation, fire, flammable substances, noxious components and the like, or to extreme temperatures, noise levels, or vibrations Performed under particularly difficult conditions Exposes the child to biological agents such as bacteria, fungi, viruses, protozoans, nematodes, and other parasites Involves the manufacture or handling of explosives and other pyrotechnic products

Pay Scheme time-based pakyaw per piece per trip quota others: Frequency of Payment daily weekly monthly others, please specify: Wage received directly by child by parent/guardian others:

Other benefits overtime Pay day rest day premium service incentive leave with pay PhilHealth Ave. work hours per day During school days _______ Non-school days ________ Injuries suffered at work (indicate date or year)

Average wage per month _________ Supervision of Parents/Guardian per week ________ per day With Without _______ others: night shift differential pay rest Work permit With 13th month pay SSS Without Pag-ibig Not applicable Ave. work hours per week During school days ____ Non-school days ______

CERTIFICATION The above findings were explained to me in a language that I understand. They are true and correct to the best of my knowledge and belief and are based on my personal declarations which I have given freely and voluntarily. _______________________________________ (Childs signature above printed name) COMMENTS Interview conducted by
(Signature above printed name)

Date:

Date