FORMS

 

Form  1

Application For Permission To Construct, Extend Or Take Into Use Any Building As A Factory

Form  2

Application  for  registration and grant of renewal of licence for the year  ........ And notice of occupation specified in sections 6 and 7

Form  3

Licence to work a factory

Form  4

Notice of change of manager

Form  5

Certificate of fitness

Form  6

Record of eye examination

Form  7

Record of limewashing, painting, etc.

Form  8 

Humidity register

Form  9

Register of workers employed for work on or near machinery in motion

Form  10

Report of examination of hoists and lifts

Form  11

Report of examination or test of pressure vessels or plant

Form  12

Register of examination of gasholders

Form  13

Report of examination of water-sealed gasholder

Form  14

Register of compensatory holidays

Form  15

Overtime muster roll for exempted workers

Form  16

Notice of periods of work for adult workers

Form  17

Register of adult workers

Form  18

Notice of periods of  work for child workers

Form  19

Register of child workers

Form  20

Register of leave with wages

Form  21

Leave book

Form  22

Nomination for payment of pay due for period of holidays in the event of death of worker

Form  23

Certificate of fitness

Form  24

Health register

Form  25

Report of accident or dangerous occurrence resulting in death or bodily  injury

Form  26

Report of dangerous occurrence which does not  result in death or bodily injury

Form  27

Notice of poisoning or disease

Form  28

Abstract of the factories act, 1948 and the Factories rules

Form  29

Annual return

Form  30

Half-yearly return

Form  31

Muster roll

Form  32

Register of accidents and dangerous occurrences

 

FORM - 1

Prescribed under Rule 4(2)

 

APPLICATION FOR PERMISSION TO CONSTRUCT, EXTEND OR TAKE INTO USE ANY BUILDING AS A FACTORY

 

1. Applicant’s name, calling and   address            :

 

2. Full name and postal address   of factory          :

 

3. Situation of factory                                                :

      (a) Province                                                         :

      (b) District                                                            :

      (c) Town or village                                               :

      (d) Nearest Police Station                                 :

      (e) Nearest railway station  or steamer ghat    :

 

 4. Particulars of plant to be  installed                     :

 

 

 

 

                                                                        Signature of applicant          :      

                                                                                        

Date                                        :

 

Note : This application shall be accompanied by the following  documents :-

 

(a)               a flow chart of the manufacturing process supplemented by a brief description of the process in its various stages;

 

(b)               plans, in duplicate, drawn to scale showing  –

 

(i)                 the site of the factory and immediate surroundings including adjacent buildings and other structures, roads, drains, etc.; and 

(ii)               the plan, elevation and necessary cross-sections of the various buildings indicating all relevant details relating to natural lighting, ventilation and means of escape in case of fire.  The plans shall also clearly indicate the position of the plant and machinery, aisles and passage-ways; and

(c)               such other particulars as the Chief Inspector may require.

*****************************************************************************************************

FORM -  2

Prescribed under Rules 6, 8(2) and 15

 

APPLICATION  FOR  REGISTRATION AND GRANT OF RENEWAL OF LICENCE FOR THE YEAR  ........ AND NOTICE OF OCCUPATION SPECIFIED IN SECTIONS 6 AND 7

(To be submitted in triplicate)

 

1. (a)   Full name of the factory                                :

 

    (b)   Factory licence number

  if already registered before                          :

 

2.(a)    Full postal address and

            situation of the factory                                   :

 

   (b)    Full postal address to  which

            communications  relating to factory

            should be sent                                               :

 

3.         Nature of manufacturing

            process or processes –

 

   (a)    carried on in the factory   in the last

            twelve months (in the case of factories 

            already in existence); and                            :

 

   (b)    to be carried on in the  factory during

            the next twelve months (in the case of

            all the factories)                                             :

 

4.         Names and values of principal                     Name                           Value 

            products manufactured during                     1. .................   .......     ………………….

            the last twelve months (in the                       2. .................   .......     ……………….

            case of factories already in                          3. .................   .......     ………………….

            existence) 

                    :

5.         (a) Maximum number of workers 

            proposed to be employed in any one

            day during the year                                       :

 

   (b)    Maximum number of workers  employed

            on any one day  during the last twelve

            months (in the case of  factories

            already in existence)                                     :

 

   (c)     Number of workers to be  ordinarily

            employed in  the factory                               :

 

6.  (a) Nature and total amount  of power

            (kilowatts) –

 

      (i)   installed; or                                                    :

      (ii)  proposed to be  installed                             :

 

      (b) Maximum amount of power (kilowatts)

            proposed to  be used                                   :

 

7.         Full name and residential address of the  

            person who  shall be the manager of the

            factory for the purposes   of the Act            :

 

8.         Full name and residential address of the

            occupier, that is  : -

 

(a)  the proprietor of the  factory in case of a

            private firm or proprietary  concern             :

 

      (b) the directors in case of  a public                 1.         .....................    

            limited liability company or firm                   2.         .....................

                                                                                    3.         .....................

                                                                              4.         .....................

                                                                              5.         .....................

 

(c) (i) the managing agent in case where a

          managing agent is employed                  :

 

            (ii) the directors of the above                       1.         .....................

                 managing agent                                       2.         .....................

                                                                              3.         .....................

                                                                              4.         .....................

 

(d) the shareholders in case of a private          1.         .....................    

            company where no managing agent           2.         .....................  

            is employed, or                                              3.         .....................    

                                                                                    4.         .....................

  

      (e) the chief administrative head in case of       

           a Government or local fund factory               :

 

9.         Full name and address of the  owner of

            the premises or building (including the

            precincts thereof) referred to in

            section 93                                                      :

 

10.       In the case of a factory constructed or

            extended after the date of

            commencement of  the rules –

 

(a)      reference number and date of approval

         of the plans  for site whether for old

         or new building and for construction

         or extension  of factory by the State

         Government/ Chief Inspector; and               :

 

(b)      reference  number and  date of

         approval of the arrangements, if any,

         made for the disposal  of trade waste

         and effluents and the name of the  

         authority granting such approval                  :

 

11. (a) Amount of fee paid                                       :           Rs. .............

 

      (b)  In case of payment in Treasury - 

    

       (i) name of Treasury                                          :

      (ii) date of payment; and                                    :

      (iii) challan number(challan to be enclosed)     :

          

      (c)  In case of transmission by crossed

            cheque -

      (i)   name of nationalised  bank                          :

     (ii)   crossed cheque number; an                        :

     (iii)  date of cheque                                              :

            (Crossed  cheque drawn in favour

            of the Chief Inspector of Factories

            to be enclosed)  

 

    (d)   In case of transmission  by crossed

            postal order -

      (i)   name of post office                                       :

     (ii)   crossed postal order  number; and             :

     (iii) date of postal order                                      :

            (Crossed postal order drawn in favour

           of the Chief Inspector of  Factories to  

           be enclosed)              

 

                                                                                    Signature of occupier           :

                                                                                    Date                                        :

 

                                                                                    Signature of manager           :

                                                                                    Date                                        :

 

 

Notes :

1.                  This form should be completed in ink in block letters or typed.

2.                   If power is not used at the time of filling up this form, but is introduced later, the fact should be communicated to the Chief Inspector of Factories immediately.

3.                  If any of the persons named against item 8 is minor, the fact should be clearly stated.

4.                  In the case of a factory where under the proviso to sub-sections (1) and (2) of section 100, a person has been nominated as the occupier, information required in item  8 should be supplied only in respect of that person.

5.                  In the case of a factory where a managing agent or agents have been appointed as occupiers under the Indian Companies Act, 1956, information required in item 8 should be supplied only in respect of that person or persons.

 

******************************************************************************************************

 

FORM - 3 

Prescribed under Rule 7(1)

LICENCE TO WORK A FACTORY

 

Licence No. ------------------               Reg.No. --------------               Date of Reg. -----------------

Licence is hereby granted to           -------------------------------------------------------------------------

for the premises known as               -------------------------------------------------------------------------

situated at                                          -------------------------------------------------------------------------

 

for use as a factory within the limits stated hereinafter, subject to provisions of the Factories Act, 1948, and the rules made thereunder.

 

The ------------------- 19..                                                                     Issuing Authority

 

 

Calendar

Year

Valid For

Fee

Date of

Payment

Excess

fee for

late

payment

Date of

payment

Signature

of the

Issuing

Authority

Maximum

number of workers on any one day

Maximum

Installed Power Capacity in Kilo watts

Granted

Under

Rule 7

 

 

 

 

 

 

 

 

Renewed

Under

Rule 8

 

 

 

 

 

 

 

 

 

TRANSFERS

 

To whom transferred

Year of transfer

Date of payment of

Transfer fee

Signature of the

Issuing Authority

 

 

 

 

 

 

 

 

 

 

AMENDMENTS

 

Year when

Amended

Amended

Date of payment of amendment fee

Additional

      fee

Date of

Payment

Signature of

the Issuing

Authority

Workers

Installed

Power Capacity in Kilowatts

 

          

 

 

 

 

 

 

 

 

 

 

 

 

 

                          

******************************************************************************************************

 

FORM - 4

 

Prescribed under Rule 16

 

NOTICE OF CHANGE OF MANAGER

 

 

1. (a)   Name of the factory                                       :

 

    (b)   Current licence number of the factory         :

 

2.         Postal address of the factory                       :

 

3.         Name of outgoing manager                         :

 

4. (a)   Name of new manager                                 :

 

    (b)   Residential address                                     :

 

    (c)    Telephone number                                        :

 

5.         Date of appointment of new manager        :

 

6.         Signature of new manager                           :

 

 

                                                                                Signature of occupier         :

                                                                                 Date                                     :

 

******************************************************************************************************

FORM - 5

Prescribed under Rule 19(2)

 

 CERTIFICATE OF FITNESS

 

1. (a) Serial  Number            : Serial Number   :

    (b) Date                              :             Date       :

                                                 

2. Name of person                : I certify that I have

    examined                             personality examined (name) .........................

 

3. Father’s Name                  : son/daughter of ........... ............................

                                                      

4. Sex                                     : ...........................

 

5. Residence                         : residing at ...........…………………………..

                                                  .............………………………………...........

 

6. Date of birth, if available  :  who is desirous of being employed  in a factory, and

    and/or certified age              that his/her age, as nearly as can be ascertained from

    or certified age                     my examination, is ........ years, and

                                                

7. Physical fitness                 : that he/she is fit for employment  in factory as an adult/child

 

8. descriptive marks             :  His /her descriptive marks are ......................

 

9. Reason for  

                          

   (a)    refusal of certificate                                

               or.....……………

   (b)    certificate being....    :            

            ……………………

 

Signature or left hand           :                       Signature or left hand thumb

Thumb impression  of the                             impression of the person examined           :

person examined                                         

 

Initials of Certifying Surgeon :                     Signature of Certifying Surgeon                  :

 

Note :

 

In case of physical disability, the exact details of the cause of the physical disability should be clearly stated.

 

******************************************************************************************************

FORM -  6

Prescribed under sub -rule (4) of rule 77

RECORD OF EYE EXAMINATION

 

Sl.

No.

Department/

Works

Name of Worker

Sex

Age(on last birthday)

Occupation

Examination of eye sight

 

Signature of opthal

mologist

Remarks

Nature

Date of employment

Date

Result

 

 

1

2

3

4

5

6

7

8

9

10

11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

******************************************************************************************************

 

FORM - 7

 

Prescribed under Rules 20, 51 and 88(8)(b)

 

RECORD OF LIMEWASHING, PAINTING, ETC.

 

Part of factory, e.g., name of room

Parts limewashed, painted, varnished or oiled, eg. walls, ceilings, wood work, etc.

Treatment, i.e., whether limewashed, painted, varnished or oiled

Date on which limewashing, painting, varnishing or oiling was carried out

Remarks

Date

Month

Year

1.       

2.       

3.       

4.       

5.       

6.       

7.       

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                                       

Signature of the manager                :

 

Date                                                    :

 

 

******************************************************************************************************

 

 

FORM - 8

 

Prescribed under Rule 28

 

HUMIDITY REGISTER

 

Department          : …………………..

 

Hygrometer          : Distinctive mark or number           : ………………………….

                                Position in department                  : ………………………….

 

Year                      : ……………………………..            Month : ………………

 

Date

Readings of hygrometer

If no humidity insert ‘none’

Remarks

Signature of the person taking the reading

Between 7 and 9 a.m.

Between 11 a.m. and 2 p.m. (but not in the rest interval)

Between 4 and 5.30 p.m.

 

Dry bulb

Wet

bulb

Dry bulb

Wet

bulb

Dry bulb

Wet

bulb

 

 

 

1st

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

13th

14th

15th

16th

17th

18th

19th

20th

-

-

-

-

31st

 

 

 

 

 

 

 

 

 

 

 Certified that the above entries are correct.

 

 

 

Signature and designation of the

person taking the readings              :    

 

 

******************************************************************************************************

FORM - 9

Prescribed under Rule 58

REGISTER OF WORKERS EMPLOYED FOR WORK ON OR NEAR MACHINERY IN MOTION

               

1.         Name of worker                                                                                 :

2.         Serial number as in the register   of workers under section 62   :

3.         Father’s name                                                                                   :

4.         Date of birth and age                                                                        :

5.         Nature of work                                                                                   :

6.         Qualifications, if any, or   period of service on similar work         :

7.         Date when tight fitting clothing   was provided                               :

8.         Remarks                                                                                            :

 

I certify that the above mentioned worker whose signature or left hand thumb impression is given below is a properly trained male adult worker who is competent to mount or shift belts, lubricate or do other adjusting operations on the machinery installed in my factory while they are in motion.

 

 

Signature or left hand thumb

impression of worker                        :

                                                                                               

Signature of Occupier          :

                                                                                   

Date                                        :

                                                                                               

******************************************************************************************************

FORM - 10

Prescribed under Rule 60 (1)

REPORT OF EXAMINATION OF HOISTS AND LIFTS

 

Occupier (or owner) of premises                            :

 

Address                                                                     :

 

1. (a)   Type of hoist or lift and identification          :      

            number or description

 

    (b)   Date of construction or reconstruction        :     

            (if ascertainable)                    

 

2.         Are all parts of the hoist or lift of good        : 

            mechanical construction, sound

            material and adequate strength 

            (so far as ascertainable) ?

 

3.         Are the following parts of the hoists            : 

            or lift properly maintained and in   

            good working order ? If not, state

            what defects have been found    

 

   (a)    Enclosure of hoistway or liftway                   :

   (b)    Landing gates and cage gate (s)                :

   (c)     Interlocks and the landing gates

            and cage gate(s)                                           :

   (d)    Other gate fastenings                                   :

   (e)    Cage and platform and fittings,

            guides, buffers, interior of the      

            hoistway or liftway                                         :

   (f)      Overrunning devices                                     :

  (g)     Suspension ropes or chain and

            their attachments                                           :

  (h)      Safety gear i.e., arrangements for     

            preventing fall of platform or

            cage brakes                                                  :

        (i) Brakes                                                           :

        (j) Worm or spur gearing                                  :

        (k) Other electrical equipment                         :

        (l) Other parts                                                     :

 

4. What parts (if any) were inaccessible ?             :

 

5. Repairs, renewals or alterations,  

   (if any) required and the period

   within which they should be executed                  :

 

6. Maximum safe working load subject to

repairs, renewals or alterations

      (if any) specified in item 5                                  :

 

 7. Other particulars                                                  :

 

 

 

 

I/We certify that on (date)...............……I/We thoroughly examined this hoist or lift and that the above is a correct report of the result.

 

                                                                                    Signature       :

                                                                                               

Qualification   :

 

Address         :

 

Date                :

 

If employed by a company association,

name and address of the company

or association      :

 


******************************************************************************************************

 

FORM - 11

 

Prescribed under Rule 62(9)(b)

REPORT OF EXAMINATION OR TEST OF PRESSURE VESSELS OR PLANT

 

1.         Name of occupier (or factory)                                              :

 

2.         Situation and address of factory                                         :

 

3.         Name, description and distinctive number of

            pressure vessel or plant                                                       :

 

4.         Name and address of manufacturer and reference  

            to their test certificate or certificate of competent

            person                                                                                    :

 

5.         Nature of process in which pressure vessel or  

            plant is used                                                                          :

 

6.         Particulars of pressure vessel or plant  : -

   (a)    Date of construction                                                              :

   (b)    Thickness of walls                                                                 :

   (c)     Date on which the pressure vessel or plant was      

            first taken into use                                                                 :

   (d)    Maximum permissible working pressure

            recommended by the manufacturer                                    :

   (e)    Design pressure, if known                                                   :

   (f)      Brief history of pressure vessel or plant was

            taken into use                                                                        :

 

7.         Date of last hydrostatic test (if any) and pressure

            applied                                                                                   :

 

8.         Is the pressure vessel or plant in open, or

            otherwise exposed to weather or to damp?                      :

 

9.         What parts (if any) were inaccessible                                 :

 

10.       What examination and test were made ?   

            (Specify pressure if hydrostatic test carried out )              :

 

11.       Condition of pressure vessel or plant    }      

            (State any defects materially affecting  }    External          :

            the maximum permissible working        }   

            pressure or the safe working of the       }     Internal           :   

            pressure vessel or plant.                         }

 

12.             Are the required fittings and appliances provided

            in accordance with the rules                                                :

 

13. (a) Are all fittings and appliances properly maintained          :     

            and in good condition?

      (b) Have the  pressure settings been checked and                :

           corrected ?           

 

14. (a) Repairs (if any) required                                                      :

      (b) Period within which the repairs should be executed         :

       (c) Any other condition which the person making the             :

           examination thinks it necessary for securing for

           working                       :

 

15.       Maximum permissible working pressure, calculated        :

            from dimensions and from the thickness and other

            data by the present examination, due allowance    

            being made for conditions of working if unusual or

            exceptionally severe.  (State minimum thickness of 

            walls measured during the  examination)          

 

16.       Where repairs affecting the maximum pressure

are required, state the  working pressure –

 

(a) before the expiration of the period specified in                 :

     item 14.       

      (b) after the expiration of such period if the required              : 

            repairs have not been completed        

       (c) after the completion of the  required repairs                      :

 

17.       Other observations                                                               :

   

 

I certify that on (date)......................the pressure vessel or plant described above was thoroughly cleaned and (so far as its construction permits) made accessible for thorough examination and for such tests as were necessary for thorough examination and that on the said date, I thoroughly examined this pressure vessel or plant, including its fittings, and that the above is a true report of my examination.

                                                                                                       

Signature                   :

Qualification               :

Address                     :

Date                            :

 

If employed by a company or

association, name and address

of the company or association        :


 

******************************************************************************************************

 

FORM - 12

Prescribed under Rule 63 (8)(b)

REGISTER OF EXAMINATION OF GASHOLDERS

 

Distinguishing Number or Letters of Gas holder

Particulars of manufacture

Particulars of examination carried out Under sub-rules 63(4) And (5)

Particulars of repair

Maker’s

Name

Date of

manufacture

No. of lifts

Max. capacity in cubic metres

Pressure thrown

by gas-holder

when full of gas

Method of examination used

Date   of examination

Name & desg. Of the person making this exam.

Nature of repairs

Date of repairs and painting

By when repairs are carried out

Remarks

1

 

2

3

4       

    5

    6

     7

   8

     9

   10

  11

 12

 13

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                                                                    Signature of Occupier or manager      :

 

 

******************************************************************************************************
FORM - 13

 

Prescribed under Rule 63 (8)(c)

 

REPORT OF EXAMINATION OF WATER-SEALED GASHOLDER

 

 

 

1.         Name of occupier (or factory)                                  :

 

2.         Situation and address of factory                             :

 

3.         Name, description, distinguishing

            number or letter and type of gasholder                   :

 

4.         Name and address of the manufacturer                 :

 

5.         (a) Number of lifts                                                      :

            (b) Maximum capacity in cubic meters                   :

            (c) Pressure thrown by holder when full of gas       :

                  full of gas

 

6.         Particulars of gas to be stored in the holder          :

 

7.         Particulars as to the condition of  : -

(a) crown                                                                    :

(b) side sheeting, including grips and cups           :

(c) guiding mechanism (Roller carriages,              :

                  rollers, pins, guide rails or ropes )                    :

(d) tank; and                                                               :

            (e) other structure, if any

                               (columns, framing and bracing)                         :

 

8.         Particulars as to the position of the

            lifts at the time of examination                                 :

 

9.         Particulars as to whether the tank and lifts             :

            were found sufficient in  level for safe working      

            and if not, as to the steps taken to remedy the

            defect.

 

10.       Date of examination and by when it was                :

            carried out

 

11.       Condition of vessel  : -

            (a) External                                                                :

            (b) Internal                                                                  :

 

12.       (a) Are all fittings and appliances properly             :

            Maintained and in good conditions?

     (b)  Repairs, if any, required and period within       :

                 which they should be executed

(c) Any other condition which the person                :

                  making the examination thinks it necessary

                  for securing safe working                       :

 

13.       Other observations                                                   :

 

 

I certify that on (date)..................... the gasholder described above was thoroughly examined and such of the tests as were necessary made on the same day and that the above is a true report of any examination.    

 

                

Signature       :

Qualification   :

Address         :

Date                :

If employed by a company or

association, name and address of the  :


 

 

******************************************************************************************************

FORM - 14

Prescribed under Rule 102(4)(a)

REGISTER OF COMPENSATORY HOLIDAYS

 

Sl.No.

 

Number in the register of workers

Name

Group or relay numbers

Numbers and date of exempting order

Year

Weekly rest days last due to the exempting order in

Date of compensatory holidays given in

Last year days carried to the next year

Remarks

January to March

April to June

July to September

October to December

January to March

April to June

July to September

October to December

1.    

2.       

3.       

4.       

5.       

6.       

7.       

8.       

9.       

10.   

11.   

12.   

13.   

14.   

15.   

16.   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

******************************************************************************************************

 

FORM - 15

 

Prescribed under Rule 103

 

OVERTIME MUSTER ROLL FOR EXEMPTED WORKERS

 

Month ending ………… 19……

 

Number in the

Register of adult

Workers

Name of exempted

worker

Department

Dates on which

overtime has been

worked

Extent of overtime

on each occasion

Total overtime hours worked

or production in case of

piece workers

Normal hours

Normal rate of pay for piece work or rate of pay per hour

Overtime rate

of pay

Normal earnings

Overtime earnings

Total earnings

Date on which

Overtime payment

made

1

2

3

4

5

6

7

8

9

10

11

12

13

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

******************************************************************************************************

FORM - 16

Prescribed under Rule 104

 

NOTICE OF PERIODS OF WORK FOR ADULT WORKERS

 

Name of the factory………………………Place………………………District………………

 

Periods of work

Groups

Delays

Men

Women

Description of Groups

Group        Nature

Letter         of work

Remarks

Total no. of men employed

Total no. of women employed

A

B

C

D

E

F

G

H

1

2

3

1

2

3

1

2

3

1

2

3

1

2

3

1

2

3

1

2

3

1

2

3

 

 

 

On working days

 

From    ..

To        ..

 

From    ..

To        ..

 

From   ..

To       ..

 

On partial

Working days

 

From    ..

To        ..

 

From    ..

To        ..

 

 

Date on which this notice is first exhibited :                      Signature of manager :

                                                                                                Date                              :

******************************************************************************************************

FORM - 17

Prescribed under Rule 105

 

REGISTER OF ADULT WORKERS

 

Sl.

No.

Name

Residential

Address

Father’s

Name

Nature

Of

Work

Letter

of group

as in

Form 16

Number

of relay

if working

in shifts

Number and date of certificate if an adolescent

Remarks

Number of certificate

And date

Token number giving

Reference to the

certificate

1

2

3

4

5

6

7

8

9

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

******************************************************************************************************

FORM - 18

Prescribed under Rule 110

NOTICE OF PERIODS OF  WORK FOR CHILD WORKERS

Name of factory ………………………    Place ………………….        District……………...

 

Children

Description of group

Remarks

Period of work

Total number of children employed

Group letter

Nature of work

 

Groups

A

B

C

Relays

1

2

1

2

1

2

                                                                                                                             A

 

                                                                                                                             B

 

From                                                                                                                     C

 

To

 

 

Date on which this notice is first exhibited :

 

                                                                                  Signature of manager             :

                                                                                  Date                                          :

******************************************************************************************************

FORM - 19

Prescribed under Rule 111

 

REGISTER OF CHILD WORKERS

 

Sl.

No.

Name

Residential

Address

Father’s name

Date of

First

Employment

Number of

certificate

and its

date

Token number

giving

reference to

certificate

Letter of

Group as in

Form 18

Number of

relay, if working

in shifts

Remarks

1

2

3

4

5

6

7

8

9

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

******************************************************************************************************

FORM - 20

Prescribed under Rule 112

 

REGISTER OF LEAVE WITH WAGES

 

 

Part I   - Adults

Part II  - Children

 

Factory           :                                                           Name of worker         :

 

Department    :                                                           Father’s Name          :

 

Sl.

No.

Sl.no. in the register

of adult/

child workers

Date

of

entry

into

service

Interruptions

Leave

due

with

effect

from

Whether leave not

desired  during the next 12 months

Date from

which the

worker is

allowed

leave

Wages for

Leave Paid in

Discharged

worker

Rem-

arks

Sickness and accidents

Authorized

Leave

Lock Out or Legal

Strike

Involuntary

unemployment

Others

Date of

Discharge

Date & amount

of payment made in lieu of leave due

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Note:- Separate page shall be allotted to each worker

******************************************************************************************************

FORM - 21

Prescribed under Rule 113(1)

 
LEAVE BOOK

 

Factory           :                                                                                      Name of worker     :

 

Department    :                                                                                      Father’s name        :

 

Sl.

No.

Sl.no. in

the register

of adult/

child workers

Date

of

entry

into

service

Interruptions

Leave

due

with

effect

from

Whether

Leave not desired

during

the next

12 months

Date from

Which the worker is

allowed

leave

Wages

for

Leave

Paid in

Discharged worker

Rem-

arks

Sickness

Authorised

Leave

Lock

out or

legal

strike

Involuntary unem

Ployment

Others

Date

of di scharge

Date & amount

of payment

made in lieu of

leave due

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Note: The leave book shall be made out separately for each worker on thick bound sheets.

 

*****************************************************************************************

FORM - 22

Prescribed under Rule 118

 
NOMINATION FOR PAYMENT OF PAY DUE FOR PERIOD OF HOLIDAYS IN THE EVENT OF DEATH OF WORKER

 

I hereby require that in the event of my death before resuming work, the balance of my pay due for the period of holidays shall be paid to ………………………………….

who is my .........................….........and resides at ........................................................

 

Witnesses      :                  Attested.

Signature       :                                                                         

Signature or left hand thumb

                                                                                     impression of worker                       :                              

Name              :

Designation   :

Address         :                                                                         

Particulars of worker such

                                                                                    as serial number in the

Signature       :                                                           register of adult/child workers,

                                                                                    section or department, etc.              :

Name              :

Designation   :  

Address         :                                                           Date                                                    :

*******************************************************************************************************
FORM - 23

Prescribed under paragraph various Schedules to Rule 120

 

CERTIFICATE OF FITNESS

 

 

Serial number            :

 

I certify that I have personally examined (name) ………………………………………………. Son of (father’s name)......................................................... residing  at (address).................………………… who is desirous of being employed as (designation) ..................…………………………. in (process, department and factory) ..........……… …………………….............................................and that his age, as nearly as an be ascertained from my examination, is..............……………..years, and that he is, in my opinion, fit/ unfit for employment in the above mentioned factory as mentioned above.

 

2.   He may be produced for further examination after a period of ..........................................

 

3.   The serial number of the previous certificate is....................

 

Signature or left hand thumb impression

of person examined         :

                                                               

Signature of Certifying Surgeon      :

                                                       Date                                                    :

       

I certify that I examined the person mentioned above on

I extend this certificate until (if certificate is not extended, the period for which the worker is considered unfit for work is to be mentioned)

Signs and symptoms

Observed during

Examination

Signature of the certifying surgeon

 

 

 

 

 

 

 

 

******************************************************************************************


FORM - 24

Prescribed under various Schedules to Rule 120

HEALTH REGISTER

 

Sl. No.

Department  /Works

Name of worker

Sex

Age (at last Birthday)

Date of employment on present work

Date of leaving or transfer to other work with reasons for discharge or transfer

Nature of job or occupation

Raw materials,

products or by- products likely to be exposed to

Dates of med ical examinati on and the res ults thereof

Signs and symptoms observed during examination

Nature of tests and results thereof

If declared unfit  for work, state period of suspension with  reasons in details

Whether certificate of unfitness issued to the workers

Re-certified fit to resume duty on

Signature of the Certifying surgeon with date

Dates

Result Fit or

Unfit

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

********************************************************************************

FORM - 25

Prescribed under Rule  121(3)

 

REPORT OF ACCIDENT OR DANGEROUS OCCURRENCE RESULTING IN DEATH OR BODILY  INJURY

 

 

E.S.I.C. Employer’s Code number         :               E.S.I.C. Insurance

Number of the injured person      :

 

1.         Name of occupier ( or factory)/employer    :

2.         Address of works / premises where the     :

            accident or dangerous occurrence

took place                                                      :

 

3.         Nature of  industry                                         :

 

4.         Branch or department and exact place     

            where the accident  or dangerous

            occurrence  took place                                 :

 

5.         Name  and address of the injured person  :

 

6.         (a) Sex                                                            :

            (b) Age (at the last   birthday)                      :

            (c) Occupation of the injured person           :

 

7.         Local E.S.I.C. Office to which the

            injured person is attached                            :

 

8.         Date, shift  and hour of accident or

            dangerous  occurrence                                :

 

9.         (a) Hour at which the injured person

           started work on the day of accident

           or dangerous occurrence                        :

 

            (b) whether wages in full or part are

     payable to him for the day of the

     accident or dangerous occurrence        :

 

10.       (a) Cause or nature  of  accident or

                  dangerous  occurrence                          :

   

        (b)  If caused by machinery : -

 

         (i)   Give the name of machine and

               the part causing the accident

               or dangerous  occurrence                     :

         (ii)  state whether it was moved

                by mechanical power at the time of

                accident or dangerous occurrence      :

 

            (c)  State exactly what the injured person

             was doing at  the time of accident

             or dangerous occurrence                      :

 

            (d)  In your opinion, was the injured

                   person at the time of accident or

                   dangerous occurrence : -

 

            (i)    acting in contravention of provisions   :

             of any law applicable to him; or

      (ii)   acting in contravention of any orders

              given by or on behalf  of his  

        employer, or                                           :

            (iii)  acting without instructions

                    from his employer?                               :

 

(e)   In case  reply to (d) (i), (ii) or (iii)

             is in the affirmative , state whether

              the act was  done for the purpose

              of and in connection with  the

              employer’s  trade  or business            :   

 

11.       In case  the accident or dangerous 

            occurrence  took place while 

            travelling in the employer’s 

            transport, state  whether  -

 

            (a)   the injured person was

              travelling  as a passenger

              to or from  his place of works               :

 

(b)   the injured person was travelling

              with the express or implied

              permission  of his employer                 :

 

(c)    the transport is being operated

        by or on behalf of the employer or

        some other person  by whom it is

        provided in pursuance of

              arrangements made with the

        employer; and                                        :

 

            (d)    the vehicle is being/not being

        operated in the ordinary course

                    of public transport  service                   :

 

12.       In case the accident or dangerous

occurrence took place while meeting

emergency, state :-  

 

(a)   its nature ; and                                       :

(b)   whether the injured person at the 

              time of accident or dangerous

        occurrence was employed  for the

        occurrence was trade or business 

              in or about  the premises at which

              the accident  or dangerous

              occurrence  took place.                        :

 

13.       Describe  briefly how the accident or

            dangerous occurrence took place              :

 

14.       Names and addresses of

            witnesses                      (1)                            :

                                                   (2)                            :

 

15.       (a) Nature and extent of injury

                 (e.g. fatal, loss of finger,

      fracture of leg, scald, scratch

                  followed by sepsis, etc.)                         :

 

(b) Location of injury (e.g. right leg,

                  left  hand, left eye, etc.)                           :

 

16.       (a)  If the accident or dangerous

            occurrence  was not fatal, state

            whether the injured  person was

            disabled for more than 48 hours           :

 

(b) date and hour of  return of work             :

 

17.       (a)  Physician, dispensary or hospital

                   from whom or which the injured 

             person received or is receiving

                   treatment                                                 :

     (b)   Name of dispensary/panel doctor

       elected by the injured person                :

 

18.       (a)   Has the injured person died ?              :

 

(b)   If so, date of death                                 :

 

 

I certify that to the best of my knowledge and belief the above particulars are correct in every respect.

 

Signature of manager/employer :

                                   

Name, designation and address

of manager/employer                       :

 

Date of dispatch of report                :

 

 

(This space is to be completed by the Inspector of  Factories)

 

District …………………………..                                         Date of receipt          :

 

Number of the accident or dangerous occurrence:           Causation                  :

 

Other particulars (e.g. fatal, leg injury, arm injury, etc.) :

 

Date of investigation         :

 

Result of investigation       :

 

******************************************************************************

 

FORM - 26

Prescribed under Rule 121(3)

 

REPORT OF DANGEROUS OCCURRENCE WHICH DOES NOT  RESULT IN DEATH ORBODILY INJURY

 

1.         Name and address of factory                      :

 

2.         Name of occupier                                         :

 

3.         Name of manager                                         :

 

4.         Nature of industry                                          :

 

5.         Branch or department and exact

            place where the dangerous occurrence

            took place                                                      :

 

6.         Date and hour of dangerous occurrence   :

 

7.         Nature of dangerous occurrence

            (State exactly what happened                     :

 

I certify that to the best of my knowledge and belief the above  particulars are correct in every respect.

 

Signature of manager           :

 

Name, designation and

address of manager             :

 

Date of despatch of

report                                      :

 

 

(To be completed by the Inspector of Factories)

 

District                                    :                        Date of receipt                     :

 

 

Number of the                                                  Causation                            :

dangerous occurrence         :

 

Date of investigation             :

 

Result of investigation          :

 

*****************************************************************************************

 

FORM - 27

 

Prescribed under Rule 122.

NOTICE OF POISONING OR DISEASE

(See instruction on reverse)

1.         Name of factory                                 :

 

2.         Address of factory                             :

 

3.         Address of office of occupier          :

4.         Residential address                         :

 

5.         Nature of industry                              :

 

6.         (a) Name of patient                           :

            (b) Works number of patient            :          

            (c) Address of patient                       :

 

7.         Precise occupation of patient          :

8.         Nature of poisoning or  disease

            from which patient   is suffering       :

 

9.         Has the case been reported to 

            the Certifying Surgeon                      :

                                                                                                                                

Signature of manager           :

                                                                                                Date                                        :

 

 

(To be filled in by the Chief Inspector)

 

Number of the case              :

 

Remarks                                :

                       

Notice of poisoning or disease
Extract from the Factories Act, 1948 (Section 89)

Where any worker in a factory contracts any disease  specified in the schedule, the manager of the factory shall send a notice thereof to such authorities, and in such form and within such time, as may be prescribed.

SCHEDULE

LIST OF NOTIFIABLE DISEASES

1.      Lead Poisoning, including poisoning by any preparation of lead or their sequelae.

2.      Lead tetra-ethyl poisoning.

3.      Phosphorous poisoning or its sequelae.

4.      Mercury poisoning or its sequelae.      

5.      Manganese poisoning or its sequelae.

6.      Arsenic poisoning or its sequelae.

7.      Poisoning by nitrous fumes.

8.      Carbon disulphide poisoning.

9.      Benzene poisoning, including poisoning by any of its homologues,  their nitro or amide derivatives or its sequelae.

10.  Chrome ulceration or its sequelae.

11.  Anthrax.

12.  Silicosis.

13.  Poisoning by halogen derivatives of the hydrocarbons of the  aliphatic series.

14.  Pathological manifestations due to : –

 

      (a) radium or other radio-active substances; and

      (b) x-rays.

 

15.  Primary epitheliomatous cancer of skin.

16.  Toxic anaemia.

17.  Toxic jaundice due to poisonous substances.

18.  Oil acne or dermatitis due to mineral oils and compounds containing mineral oil base.

19.  Byssinosis.

20.  Asbestosis.

21.  Occupational or contact dermatitis caused by direct contact with chemicals and paints. These are of two types that is, primary  irritants and allergic sensitizers.

22.  Noise induced hearing loss (exposure to high noise levels).

 

Extract from the ...................…………….Factories Rules, 19....(Rule...)

 

A notice in Form 27 should be sent forthwith both to the Chief Inspector and to the Certifying Surgeon, by the manager of a factory in which there occurs a case of lead, phosphorous, mercury, manganese, arsenic, carbon bisulphide or benzene poisoning by nitrous fumes or by halogens or halogen derivatives of the hydrocarbons of aliphatic series; or of chrome ulceration, anthrax, silicosis, toxic anaemia, toxic jaundice, primary epitheliometous cancer of skin, or of pathological manifestations due to radium or other  radio-active substances or x-rays.

************************************************************************************

 

FORM - 28

 

Prescribed under Rule 124

ABSTRACT OF THE FACTORIES ACT, 1948 AND THE .........................

FACTORIES RULES,....................

 

(To  be  affixed in a conspicuous and convenient place at or  near  the main entrance to the factory )

 

Interpretation

 

1.      “Factory” means any premises including the precincts thereof  -

 

(i) wherein ten or more workers are working, or were working on any day of the preceding twelve months, and in any part of which a manufacturing process is being carried on with the aid of power, or is ordinarily so carried on, or whereon  twenty or more workers are working, or were working on any day of the preceding twelve months, and in any part of which a manufacturing process is being carried on without the aid of power, or is ordinarily so carried on but  does not include a mine subject to the operation of  the  Mines   Act,  1952  (35 of 1952), or a mobile unit belonging  to  the  armed  forces  of the Union, a railway running shed or a hotel,  restaurant or eating place.      

 

Explanation  :-  For  computing the number  of  workers  for  the  purposes of this clause all the workers in different relays in a day  shall be taken into account.

 

2       .“Worker”  means  a person employed, directly or through  any  agency (including  a  contractor)  with  or without the  knowledge of  the principal employer,  whether for remuneration or not, in any manufacturing  process, or in any other kind of work incidental to, or connected with, the manufacturing process, or the subject of  the  manufacturing process; but does not include any member of the armed  forces of the Union.

 

3.          “Manufacturing process” means any process for  -

 

(i)           making,  altering, repairing, ornamenting,  finishing,  packing,  oiling,   washing,  cleaning,  breaking  up,   demolishing, or otherwise  treating or adapting any article or substance with  a  view to its use, sale, transport, delivery or disposal, or

 

(ii)                  pumping oil, water, sewage or any other substances; or

 

(iii)                generating, transforming or transmitting power; or

 

(iv)                composing   types  of  printing,  printing  by   letter   press,   lithography,  photogravure  or other similar  process  or  book   binding; or

 

(v)                  constructing, reconstructing, repairing, refitting, finishing or  breaking up ships or vessels ; or

 

(vi)                preserving or storing any article in cold storage.

 

Working hours, holidays, intervals after rest, etc.

 

4.            Hours  of  work for adults (Sections 51 and 54).-  No  adult  worker  shall  be required or allowed to work in a factory for more than  48 hours in any week and for more than 9 hours in any day.     

 

5.            Relaxation  of hours of work for adult (Section 64) .- The ordinary limits on working hours of adults may be relaxed in certain  special  cases,  e.g.,  workers engaged on urgent repairs;  in  work in the  nature  or preparatory or complementary work which must  necessarily  be  carried on outside the limits laid down for the general  working of the factory; in work which is necessarily so intermittent  that the intervals for rest; in any work which for technical reasons must  be carried on continuously; in making or supplying articles of prime  necessity   which  must  be  made  or  supplied  every  day; in a manufacturing process which cannot be carried on except during fixed   seasons,  or at times dependent on the irregular action  of  natural  forces;  in engine rooms or boiler houses or in attending  to  power plant or transmission machinery; in the printing of news papers, who are held up on account of the breakdown of machinery; in the loading or unloading of railway wagons or lorries or trucks; and in any work  which is notified by the State Government in the Official gazette as  a work of national importance.

 

Except  in  the  case of urgent repairs, the  relaxation  shall  not  exceed the following limits of work inclusive of overtime :-

 

(i)                       the  total number of hours of work in any day shall  not  exceed  ten;

(ii)                     the spread over inclusive of intervals for rest, shall not exceed  12 hours in any one day;

(iii)                   the total number of hours of work in a work, including overtime,  shall not exceed sixty;    

(iv)                   the  total  number of hours of overtime work  shall  not  exceed  fifty for any one quarter.

 

6.            Payment for overtime (Section 59).- Where a worker works in a factory for more than 9 hours in any day or for more than 48  hours  in  any week, he shall, in respect of overtime work, entitled to wages at the rate of twice his ordinary rate of wages.

 

7.         Exemption of supervisory staff (Section 64).- Chapter VI, other than   the provisions of clause (b) of sub-section (1) of section 66 and of  the proviso to that sub-section, of the Act-Working hours of  adults -  does  not apply to persons holding positions  of  supervision  or   management or are employed in a confidential position in a  factory, provided  that where the ordinary rate of wages of such person  does  not  exceed  rupees  seven hundred and fifty  per  month,  they  are  entitled  to extra wages in respect of overtime work  under  Section 59.

 

8.         Weekly  holiday  (Adults) (Section 52).- No adult  worker  shall  be  required  or  allowed to work in a factory on the first day  of  the week, unless -

 

(a)                he  has, or will have, a holiday for a whole day on one  of  the  three days immediately before or after the said day, and

 

(b)                the  manager  of  the factory has, before the said  day  or  the  substituted day under clause (a) whichever is earlier, -

 

(i)                 delivered  a  notice at the office of the Inspector  of  his  intention to require the worker to work on the said day  and of the day which is to be substituted; and

 

(ii)               displayed a notice to that effect in the factory:

 

Provided that no substitution shall be made which will result in any  worker working  for more than ten days consecutively without a holiday for a  whole day.

 

9.        Compensatory holidays (Section 53)- Where a worker in a factory, as  a result of exemption from the ordinary provision relating to weekly holidays,  is  deprived of any of the weekly holidays, he  shall  be allowed,  within the month in which the holidays were due to him  or within   the   two  months  immediately   following   that   month, compensatory holidays of equal number of the holidays so lost.

 

 

10.     Intervals  for rest for adults (Section 55 and 56).- The periods  of work  of adult workers in a factory each day shall be fixed that  no  period  shall exceed 5 hours and that no worker shall work for  more   than 5 hours before he has had an interval for rest of at least half an  hour  and  that inclusive of his intervals for  rest  shall  not  spread  over more than ten and a half hours in any day or, with  the permission of the Chief Inspector in writing, 12 hours.

 

11.       Prohibition of double employment (Section 60,71 & 99).- No child or, except in certain circumstances, an adult worker, shall be  required or allowed to work in any factory on any day on which he has already been working in  any other factory.

 

 

If  a  child works in a factory on any day on which he  has  already been working in another factory, the parent or guardian of the child or the person having custody of or control over him or obtaining any direct benefit from his wages, shall be punishable with fine,  which may extend to Rs. 50 unless it appears to the court that the child so worked without the consent or connivance of such parent, guardian or   person.

 

12.              Prohibition  of  employment of children under 14 (Section  67).-  No  child who has not completed his fourteenth year shall be required or allowed to work in any factory.

 

13.              ours of work for children (Section 71).- No child shall be employed  or  permitted to work in any factory for more than four and  a  half hours  in  any  day  and  during  the  period  of  at  least  twelve   consecutive  hours which shall include the interval between 10  P.M. and  6. A.M.  The  periods of work of all  children  employed  in  a   factory shall be limited to two shifts which shall not  overlap or spread over more than 5 hours each and each child shall be  employed in only one of the relays.

             

The provision relating to weekly holidays shall also apply to  child  workers  and  no  exemption form this provision may  be  granted in respect  of any child.

 

14.       Prohibition of employment of women (Section 66).- No women shall  be  required or allowed to work in any factory except between the  hours of 6 A.M. and 7 P.M. The State Government may vary those limits  or  exempt  this restriction in case of women working in fish-curing  or fish-canning factories.

 

Leave with wages

 

15.       Leave  with wages (Section 79, 80 and 83 and Rules).-  Every  worker  who has worked for a period of 240 days or more in a factory  during a calendar year shall be allowed during the subsequent calendar year  leave with wages for a number of days calculated at the rate of -

 

(i)   if an adult, one day for every twenty days of work performed  by    him during the previous calendar year; and

 

(ii)  if  a child, one day for every 15 days of work performed by  him  during the previous calendar year.

 

 

Explanation. 1. For the purpose of this sub-section –

 

(a)     any days of lay off, by agreement or contract or as  permissible  under the standing orders;

 

(b)     in the case of female worker, maternity leave for any number  of  days not exceeding twelve weeks; and

 

(c)      the leave earned in the year prior to that in which the leave is   enjoyed;

 

shall  be  deemed  to be days on which the worker has  worked  in  a   factory for the purpose of computation of the period of 240 days  or  more, but he shall not earn leave for these days.      

      

Explanation 2.- The leave admissible under this sub-section shall be exclusive of all holidays whether occurring during or at either end of the period of leave.

   

For the leave allowed to him, a worker shall be paid at a rate equal to  the  daily  average of his total full-time earning, for the  days  on  which he actually worked during  the month immediately preceding the leave exclusive of any overtime and bonus, but inclusive of dearness   allowance and the cash equivalent of the advantage accruing  through   the  concessional  sale to  the worker of  food  grains  and  other  articles.

      

A worker whose service commences otherwise than on the first day  of  January shall be entitled to leave with wages at the rate  indicated   above,  if he has worked for two-thirds of the total number of  days  in the remainder of the calendar year.

 

If  a  worker is discharged or dismissed from service or  quits  his  employment or is supperanuated or dies while in service, during  the  course  of the calendar year, he or his heir or nominee as the  case may  be, shall be entitled to wages in lieu of the quantum of  leave  to  which   he  was  entitled  immediately  before  his   discharge, dismissal,  quitting  of  employment,  superannuation  or death, calculated  at the rates specified above, even if he had not  worked   for the entire period specified above.  Such payment shall be made –

 

(i)   whether   the  worker  is  discharged  or  dismissed  or  quits  employment, before the expiry of the second working day from the day of such discharge, dismissal or quitting; and

 

(ii)  where  the  worker is superannuated  or dies while in service, before the expiry  of two months from  the  date  of   such superannuation or death.

 

If the employment of a worker who is entitled to leave with wages is  terminated  by the occupier before he has taken the entire leave  to  which  he is entitled, or if having applied for and having not  been  granted  such leave, the worker quits his employment before  he  has   taken  the  leave,  the occupier of the factory shall  pay  him  the  amount  payable in respect of the leave not taken, and such  payment shall be made before the expiry of the second working day after  the  day   on which his employment is terminated and a worker  who  quits his employment, on or before the next pay day.

 

The  manager  shall maintain a register of leave with wages  in  the   prescribed Form 20 and shall provide each worker with a book  called  the “Leave Book” in the prescribed Form 21.  The leave book shall be   the  property of the worker and the manager or his agent  shall  not  demand  it  except  to  make entries of the  dates  of  holidays  or   interruptions in service, and shall not keep it for more than a week at  a  time.  If a worker loses his leave book,  the  manager  shall   provide  him with  another  copy  on  payment of  paise ..............and shall complete it from his record.

 

Health

16.       Cleanliness  (Section 11).- Except in cases specially exempted,  all    inside  walls and partitions, all ceilings or  tops of rooms and  all   walls, sides and tops of passages and stair-cases in a factory shall  be  kept   whitewashed  or  colour washed.   The   whitewashing   or   colour washing shall be carried out at least once in every period  of   fourteen  months.  The floor of every workroom shall be  cleaned  at  least  once  in  every week by washing,  using  disinfectant,  where  necessary, or by some other effective method.

 

17.       Disposal  of  wastes  and  effluents  (Section 12).-   Effective   arrangements  shall  be made in every factory for the  treatment  of  wastes  and  effluents due to the manufacturing process  carried  on  therein, so as to render them innocuous, and for their disposal.

 

18.       Ventilation  and temperature (Section 13).- Effective  and  suitable    provision   shall  be  made  in  every  factory  for  securing   and  maintaining   in   every  workroom  adequate  ventilation   by   the    circulation  of fresh air and such a temperature as will  secure  to  workers therein reasonable conditions of comfort and prevent  injury to health.        

 

19.       Overcrowding (Section 16).- Unless exemption has been granted, there shall be in every workroom of a factory in existence on the date  of commencement  of this Act at least 350 cubic feet and of  a  factory  built after the commencement of this Act at least 500 cubic feet  of  space  for  every worker employed therein, and for this  purpose  no account shall be taken of any space which is more than 14 feet above     the level of the floor of the room.

 

 

20.       Lighting (Section 17).- In every part of a factory where workers are  working   or  passing,  there  shall  be  provided  and   maintained  sufficient and suitable lighting, natural  artificial, or both.

 

21.       Drinking  water (Section 18 and Rules).- In every factory  effective  arrangements  shall  be  made to provide and  maintain  at  suitable points  conveniently  situated for all workers employed  therein, a sufficient supply of wholesome drinking water.

 

In  every  factory  wherein more than  250  workers  are  ordinarily  employed  the drinking water shall, during hot weather be cooled  by  ice or other effective methods.  The cooled drinking water shall  be   supplied  in  every  canteen, lunchroom and  restroom  and  also  at   conveniently accessible points throughout the factory.

 

22.       Latrines and  urinals  (Section 19 and Rules).-  In  every  factory  sufficient  latrine and urinal accommodation of the prescribed  types   (separate  enclosed accommodation for male and female workers)  shall  be  provided conveniently situated and accessible to workers at  all times  while they are at the factory.  Every latrine shall be  under  cover  and so partitioned off as to secure privacy and shall have  a   proper  door  and  fastenings.  Sweepers  shall  be  employed  whose   primary  duty  it  would be to keep  clean  latrines,  urinals  and washing places.

 

23.       Spittoons (Section 20).- In every factory, there shall be provided a  sufficient number of spittoons of the type prescribed in convenient places and they shall be maintained in clean and hygienic condition.   No  person shall spit within the premises of factory except  in  the  spittoons  provided for purpose.  Whoever spits in contravention  of   this  provision  shall be punishable with fine  not  exceeding  five   rupees.

 

Safety

24.       Fencing of machinery (Section 21).- In every factory dangerous parts  of  machinery  e.g., every moving part of a prime mover and every flywheel connected to prime mover, etc. etc. shall be securely fenced  by safeguards of substantial construction which shall be  constantly  maintained  and kept in position while the parts of  machinery  they are fencing in motion or in use.

 

25.       Work on or near machinery in motion (Section 22).- No woman or young    person shall be allowed in any factory to clean, lubricate or adjust   any  part  of  a prime mover or any  transmission  machinery  is  in  motion, or to clean, lubricate or adjust any part of any machine  if  the  cleaning,  lubrication or adjustment thereof would  expose  the woman or young person to risk of injury from any moving part  either  of that machine or of any adjacent machinery.

 

26.       Employment of young persons on dangerous machines (Section 23).-  No  young  person  shall work at any machine declared  to  be  dangerous unless  he  has been fully instructed as to the dangers  arising  in  connection  with the machine and precautions to be observed and  has received  sufficient  training in work at the machine or is  under adequate  supervision by a person who has a thorough  knowledge  and  experience of the machine.

 

27.       Casing  of new machinery (Section 26).- In all machinery  driven  by  power  and installed in any factory after the commencement  of  this  Act,  every set screw, bolt or key on any revolving shaft,  spindle,   wheel  or pinion shall be so sunk, encased or otherwise  effectively  guarded  as to prevent danger; all spur, worm and other toothed or friction gearing which does not require frequent adjustment  while  in  motion shall be completely encased, unless it is so situated  as  to as safe as it would be if it were completely encased.

 

Whoever  sells  or lets on hire or, as agent of a seller  or  hirer,  causes  or procures to be sold or let on hire, for use in a  factory  any  machinery  driven  by power which does not  comply  with  these  provisions or any rules made under this section, shall be punishable  with  imprisonment  for a term which may extend to three  months  or with fine which may extend to five hundred rupees or with both.

28.       Prohibition  of employment of women and children near cotton  openers  (Section 27).- No woman or child shall be employed in any part of  a  factory for pressing cotton in which a cotton opener is at work.

 

29.       Excessive weights (Section 34 and Rules).- No woman or young  person  shall, unaided by another person, lift, carry or move by hand or  on  head, any material, article, tool or appliance exceeding the maximum  limit in weight set out in the following schedule :-

 

SCHEDULE

             Persons                                           Maximum weight of material,

article, tool or appliance

 

  (a) Adult male                                              55 Kilograms

  (b) Adult female                                           30 Kilograms

  (c) Adolescent male                                    30 Kilograms

  (d) Adolescent female                                20 Kilograms

  (e) Male child                                               16 Kilograms

  (f) Female child                                           14 Kilograms

 

30.       Protection of eyes (Section 35 and Rules).- Effective  screens  or suitable  goggles  shall be provided for the protection of persons  employed in or in the immediate vicinity of processes which  involve  risk of injury to eyes from particles or fragments thrown off in the  processes  or  which  involve risk of injury to eyes  by  reason  of   exposure to excessive light or infra-red or ultra-violet radiations.

 

31.       Precautions  in case of fire (Section 38 and Rules).- Every  factory  shall be provided with adequate means of escape in case of fire  for the  persons employed therein.   The doors affording exit  from  any  room shall, unless they are of sliding type, be constructed to  open  outwards.   Every  window, door or other exit affording a  means  of  escape  in  case of fire, other than the means of exit  in  ordinary  use,  shall be distinctively marked.  Effective and clearly  audible   means of giving warning in case of fire to every person employed  in  the factory shall be provided.  Effective measures shall be taken to  ensure  that   wherein  more  than  twenty  workers  are  ordinarily  employed  in any place above the ground floor, or wherein  explosive  or highly inflammable materials are used or stored, all the  workers  are familiar with the means of escape in case of fire and have  been  adequately trained in the routine to be followed in such case.

Welfare

32.       Washing  facilities  (Section  42  and  Rules).-  In  every  factory   adequate  and suitable facilities for washing shall be provided  and maintained  for  the use of the workers  therein.   Such  facilities   shall  include  soap  and nail brushes or other  suitable  means  of  cleaning  and  the facilities shall be conveniently  accessible  and  shall be kept in a clean and orderly condition.

 

If female workers are employed separate washing facilities shall  be  provided  and  so enclosed or screened that the  interiors  are  not  visible from any place where persons of the other sex work or pass.

 

33.       Facilities for storing and drying clothing (Section 43 and  Rules).-  In  the case of certain dangerous operations e.g.,  lead  processes, liming  and tanning of raw hides and skins etc. suitable places  for keeping clothing not worn during working hours and for the drying of  wet clothing shall be provided and maintained.

 

34.       Facilities  for  sitting (Section 44).- In  every  factory  suitable arrangements  for sitting shall be provided and maintained  for  all  workers  obliged to work in a standing position in order  that  they may take advantage of any opportunities for rest which may occur  in   the course of their work.

 

35.       First-aid and ambulance room (Section 45).- There shall in every  factory  be provided and maintained sops to be readily  accessible  during all working hours first-aid boxes or cupboards equipped  with the  prescribed contents.  Each first-aid box or cupboard  shall  be kept  in  the charge of a separate responsible person  who holds a certificate  in  first-aid  treatment  recognised by  the  State  Government who shall always be available during the working hours of  the factory.

     

In  every  factory  wherein  more than 500  workers  are  ordinarily  employed there shall be provided and maintained an ambulance room of  the prescribed size, containing the prescribed equipment, and in the  charge  of such medical and nursing staff as may be  prescribed  and  those  facilities shall always be made readily available during  the   working hours of the factory.

 

36.       Canteens  (Section  46 and Rules).- In specified  factories  wherein  more than 250 workers are ordinarily employed, a canteen or canteens  shall be provided and maintained by the occupier for the use of  the  workers.  Food, drink and other items served in the canteen shall be  sold  on a non-profit basis and the prices charged shall be  subject  to  the approval  of a Canteen Managing Committee  which shall be appointed  by  the manager and shall consist of an equal  number of  persons  nominated by the occupier and elected by the workers.   The  number of elected workers shall be in the proportion of 1 for  every  1,000  workers  employed in the factory, provided that  in  no  case shall there be more 5 or less than 2 workers on the Committee.   The Committee shall be consulted from time to time as to the quality and   quantity of food stuffs to be served in the canteen, the arrangement  of  the  menus,  etc. etc.  Where the canteen is managed  by a co-operative  society,  it  is  not necessary  to  appoint  a  Canteen   Managing  Committee and the prices to be charged  may  include a margin  of  profit  up to  a maximum of 5 per cent  of  its  working  capital.

 

37.       Shelters, restrooms and lunchrooms (Section 47).- In every  factory  wherein more than 150 workers are ordinarily employed, adequate  and  a  suitable  lunchroom,  with provision for  drinking  water,  where  workers  can  eat  meals  brought by them,  shall  be  provided  and  maintained for the use of the workers.

 

38.       Creches (Section 48 and Rules).- In every factory wherein more  than  30 women workers are ordinarily employed there shall be provided and maintained  a suitable room or rooms for the use of  children  under  the age of six years of such women.  The creche shall be  adequately  furnished and equipped and in particular there shall be one suitable  cot or a cradle with the seating accommodation for the use of  each  mother  while  she  is  feeding or attending to  her  child,  and  a   sufficient supply of suitable toys for older children.

 

There  shall be in or adjoining the creche a suitable  washroom  for   the washing of the children and their clothing.  An adequate  supply  of clean clothes, soap and clean towels shall be made available  for each child while it is in the creche at least a quarter litre of clean  pure milk  shall  be  available  for  each  child  on  every  day  it  is accommodated  in the creche and the mother of such a child shall  be allowed  in the course of her daily work suitable intervals to  feed the  child.   For children above two years of age,  there  shall  be  provided, in addition, an adequate supply of wholesome  refreshment.   A  suitably  fenced  and shady open air playground  shall  also  be  provided for the older children.  

 

39.       Welfare Officers (Section 49).- In every factory wherein 500 or more  workers  are  ordinarily employed the occupier shall employ  in  the factory such number of Welfare Officers as may be prescribed.

 

Special Provisions

 

40.       Dangerous  operations (Section 87 and Rules).- Employment of  women,  adolescents  and  children is prohibited or  restricted  in  certain operations  declared  to be  dangerous,  e.g., electroplating, manufacture and repair of electric accumulators, glass  manufacture, grinding or glazing of metals, manufacture and treatment of lead and  certain compounds of lead, sand blasting, etc.

 

41.       Notice of accidents (Section 88 and Rules).- When an accident occurs  which  results in the death of any person or which results  in  such  bodily injury to any person as is likely to cause his death, or  any dangerous occurrence specified in the schedule annexed hereto takes place in a factory, the manager of the factory shall forthwith send a notice thereof by telephone, special messenger or telegram to  the Inspector  and  the Chief Inspector. When any accident or any dangerous occurrence specified in the schedule annexed hereto, which results  in the death of any person or which results in such  bodily  injury to any person as is likely to cause his death, takes place in a  factory,  forthwith notice shall be sent also  to  the  District  Magistrate  or Sub-divisional Officer, to the  officer-in-charge  of the  nearest police station; and to the relatives of the  injured  or  deceased person.

 

SCHEDULE

 

1.   Bursting  of  a plant used for containing or supplying  steam  under   pressure greater than atmospheric pressure.

 

2.      Collapse  or  failure  of a crane, derrick, winch,  hoist  or  other  appliances used in raising or lowering persons or goods, or any part  thereof, or the overturning of a crane.

 

3.      Explosion,  fire,  bursting  out, leakage or escape  of  any  molten  metal,  or hot liquor or gas causing bodily injury to any person  or  damage  to any room or place in which persons are employed, or  fire  in  rooms  of cotton pressing factories when a cotton opener  is  in  use.

 

4.      Explosion  of  a  receiver or container used for the  storage  at  a  pressure  greater  than  atmospheric pressure of any  gas  or  gases (including   air) or  any  liquid  or  solid resulting  from   the  compression of gas.

 

5.      Collapse or subsidence of any floor, gallery, roof, bridge,  tunnel,  chimney, wall, building or any other structure.

 

42.       Notice of certain diseases (Section 89 and Rules).- Where any worker   in a factory contracts any of the following diseases, the manager of   the  factory shall send notice in Form 27 thereof forthwith both  to  the Chief Inspector and the Certifying Surgeon :-

 

Lead, phosphorus, mercury, manganese, arsenic, carbon bi-sulphide or benzene  poisoning; or poisoning by nitrous fumes or by halogens or halogen derivatives of the hydrocarbons of the aliphatic series;  or of  chrome  ulceration,  anthrax, silicosis,  toxic  anaemia,  toxic jaundice,  primary  opitheliomatous  cancer  of   the   skin,   or  pathological  manifestations  due to radium or  other  radio-active  substances or x-rays.

 

43.       No  charge for facilities and convenience (Section 114).- No fee or charge  shall  be  realised  from  any  worker  in  respect  of  any arrangements  or  facilities to be provided, or  any  equipments or appliances to be supplied by the occupier under the  provisions  of  this Act.

 

44.       Powers of Inspectors (Sections 9 and 82).- Inspectors have power  to inspect  factories  any  time  and may  require  the  production  of registers,  certificates,  etc. prescribed under the  Act  and  the  Rules.

 

Any Inspector may institute proceedings on behalf of any workers  to  recover  any  sum  required  to be paid by  an  employer  under  the  provisions relating to leave with wages, which the employer has  not  paid.

45.       Obligations of workers (Section 97 and 111).- No worker in a factory :

 

(i)         shall   wilfully  interfere  with or misuse  any  appliance, convenience or  other  thing  provided in a factory  for  the  purposes  of  securing the health, safety  or  welfare  of  the  workers therein;

 

(II)        shall  wilfully  and without any reasonable  cause  do  anything likely to endanger himself or others; and

 

(iii)             shall  wilfully  neglect to make use of any appliance  or  other thing  provided in the factory for the purpose  of  securing  the health or safety of the workers therein.

 

If any worker employed in a  factory  contravenes  any  of   these   provisions  or  any  rule  or order  made  thereunder  he  shall  be  punishable  with imprisonment for a term which may extend  to  three  months, or with fine which may extend to Rs. 00, or with both.

     

If  any  worker employed in a factory contravenes any  provision  of    this  Act or any rules or orders made thereunder, imposing any  duty  or liability on workers, he shall be punishable with fine which  may  extend to Rs. 20.

 

46.       Certificates of fitness (Sections 69, 70 and 98).- No child who  has completed his fourteenth year or an adolescent shall be required or allowed  to  work  in any factory unless a  certificate  of  fitness   granted  with reference to him is in the custody of the  manager  of  the  factory  and such child or adolescent carries, while he is  at  work,  a  token  giving a reference to such  certificate.   Any  fee  payable  for  such a certificate shall be paid by the occupier  and shall  not  be  recoverable from the young person,  his  parents  or  guardian.

 

An adolescent who has been granted a certificate of fitness to  work  in a factory as an adult and who while at work in a factory  carries a token giving reference to the certificate shall be deemed to be an adult for all the purposes of the provisions of the  Act relating to the working hours of adults and the employment of young persons.  An  adolescent who has not been granted a certificate of fitness to work  in  a factory as an adult shall, notwithstanding his age, be  deemed  to be a child for all the purposes of this Act.

 

Whoever knowingly  uses or attempts to use, as  a  certificate  of  fitness  granted  to  himself,  a  certificate granted  to  another adolescent to work in a factory as an adult, or who having  procured  such a certificate knowingly allows it to be used, or an attempt  to use  it  to  be made, by another person, shall  be  punishable  with  imprisonment  for a term which may extend to two months or with  fine  which may extend to Rs. 100 or with both.

 

47.       Registers, notices and returns (Sections 61, 62, 63, 72, 73, 74  and 110 and Rules).- A register of adult workers in the prescribed  Form 17  and a register of child workers in the prescribed Form 19  shall  be maintained by the manager of every factory.

 

A  notice of periods of work for adults and a notice of  periods  of  work  for  children  in  the prescribed forms 16  and  18  shall  be  correctly  maintained  and  displayed in every  factory.   No  adult  worker or child shall be required or allowed to work in any  factory otherwise  than  in  accordance with  their  respective  notices  of  periods of work displayed in the factory.

 

The  owners,  occupiers or managers of factories  shall  submit  the  prescribed periodical returns to the Inspector regularly.


*******************************************************************************

FORM - 29

Prescribed under Rule 125

ANNUAL RETURN

 

For the year ending 31st December, 19..........

 

1.         Registration number of factory        :

2.         Name of factory                                 :

3.         Name of occupier                             :

4.         Name of the manager                       :

5.         District                                                :

6.         Full postal address of factory           :

7.         Nature of industry                              :

Number of workers and particulars of employment

 

8.         No. of days worked in the year        :

9.         No. of man-days worked during the year

            (a) Men                                               :

            (b) Women                                         :

            (c) Children                                        :

 

10.       Average number of workers employed daily         (See explanatory note)

    

(a) Adults                    (i) Men            :

                                                (ii) Women     :

 

            (b) Adolescents         (i) Male           :

                                                (ii) Female     :

 

            (c) Children                (i) Male           :

                                                (ii) Female     :

 

11.       Total no. of man-hours worked including  overtime.

 

(a)   Men                       :

            (b) Women                 :

            (c) Children                :

 

12.       Average number of hours worked per  week (See explanatory note)

 

            (a) Men                       :

            (b) Women                 :

            (c) Children                :

 

13.       (a)  Does the factory carry out any process or operations declared as dangerous under Section 87 (See         Rule 116):

 

(b)   If so, give the following information

 

-----------------------------------------------------------------------------------------------------------------------

Name of the dangerous process     Average no. of persons employed daily in each

Or operations carried on                  of the processes or operations given in Col.1

1                                                                                                                                             2

-----------------------------------------------------------------------------------------------------------------------

i)

 

ii)

 

iii) etc.

------------------------------------------------------------------------------------------------------------------------

Leave with Wages

 

14.       Total number of workers employed   during the year                        :

            (a) Men                                   :

            (b) Women                             :

            (c) Children                            :

 

15.       Number of workers who were entitled   to annual leave wit wages during the  year  

    

            (a) Men                                   :

            (b) Women                             :

            (c) Children                            :

 

 16.      Number of workers who were granted  leave during the year    

            (a) Men                                   :

            (b) Women                             :

            (c) Children                            :

 

17. (a) Number of workers who were

            discharged, or dismissed from

            the service, or quit employment,

            or were superannuated, or died

            while in service during the year  

:

      (b) Number of such workers in respect 

            of when wages in lieu of leave

             were paid                                                      :

 

18. (a) Number of Safety Officers required

            to be appointed as per notification

            under Section 40-B    

        :

      (b) Number of Safety Officers

            appointed                                                       :

Ambulance room

 

19.       Is there an ambulance room provided

            in the factory as required under

            Section 45 ?                                                  :

 

Canteen

 

20.       (a) Is there a canteen provided in

                  the factory as required under

                 Section 46?                                              :                      

 

            (b) Is the canteen provided managed

 

             i) departmentally, or                                     :

            ii) through a contractor?                               :

Shelters or Rest Rooms and Lunch Rooms

 

21.       (a) Are there adequate and suitable

                  shelters or rest rooms provided in

                  the factory as required under

                  Section 47?                                             :

 

            (b) Are there adequate and suitable

            lunch rooms provided in the factory

            as required under Section 47?              :

Creches

 

22.       Is there a Creche provided in the

            factory as required under Section 48 ?      :

23.       (a)  Number of Welfare Officers to be

                 appointed as required under

                Section 49                                                :

 

            (b) Number of Welfare Officers

            appointed                                                 :

 

Accidents

 

24.       (a) Total number of accidents

                  (See explanatory notes)

 

           i)    Fatal                                                         :

            ii)   Non-Fatal                                                 :

 

(b) Accidents in which workers

           returned to work during the year

           to which this return relates                      :

 

      i)   Accidents (workers injured)

                 occurring during the year in

                 which injured workers returned

                 to work during the same year

 

            (aa)  Number of accidents                     :

            (bb)  Man-days lost due to accidents    :

:

            ii)  Accidents (workers injured)

                  occurring in the previous year

                  in which injured workers

                  returned to work during the

                  year to which this return  relates

 

            (aa) Number of accidents                      :

            (bb) Man-days lost due to accidents     :

 

 

      (c)  Accidents (workers injured)

                  occurring during the year in

                  which injured workers did not

                  return to work during the

                  year to which this return relates

 

           i) Number of accidents                           :

            ii) Man-days lost due to accidents        :           

 

Certified that the information furnished above is to the best of my knowledge and belief, correct.

 

 

Signature of the manager

Date

 

Explanatory Notes :

 

1.         The average number of workers employed daily should be calculated by  dividing  the aggregate number of attendance on working days  (that  is, man-days  worked by the number of working days in the year. In reckoning attendance, attendance by temporary as well as permanent employee should be counted, and all employees should be included, whether they are employed directly or under contractors.  Attendance on separate shifts (e.g. night and day shifts) should  be counted separately. Days  on which the factory was closed  for  whatever  cause, and days on which the manufacturing processes are  not   carried  on  should   not  be  treated  as  working  days.   Partial  attendance  for  less than half a shift on a working day  should  be ignored,  while  attendance  for half a shift or more  on  such  day should be treated as full attendance.

 

 

2.         For seasonal  factories, the average  number of  workers  employed during  the  working  season and the  off-search should be given separately.  Similarly the number of days worked and average  number of  manhours  worked  per week during  the  working  and  off-season should be given  separately.

 

 

3.         The average  number of hours worked per week means the total  actual   hours  worked  by  all workers during the year excluding  the rest intervals but  including overtime work divided by the product  of   total number of workers employed in the factory during the year and 52.   In case  the  factory has not worked  for the  whole  year,  the  number of  weeks during which the factory worked  should be  used  in  place of the figure  52.

 

 

4.         Every  person killed  or injured should be treated  as one  separate accident.  If in one occurrence  six persons were injured or killed, it should be counted as six accidents.

 

5.         In item 24(a , the number of accidents which took place during the year  should  be given.  In case of non-fatal accidents only these accidents which prevented  workers from working  for 48 hours or  more, should be  indicated.


***************************************************************************************************************************

 

FORM - 30

Prescribed  under Rule 125

 

HALF-YEARLY RETURN

 

 

For the  half-year  ending 30th  June, 19.…./31 December , 19.….

1.         Registration number of factory        :

2.         Name of factory                                 :

3.         Name of occupier                             :

4.         Name of manager                             :

5.         District                                                :

6.         Postal address of factory                 :

7.         Nature of industry                              :

8.         Average number of workers

            employed  daily

            (See  explanatory note)

   

(a) Adults -                 i. Man              :

                                                ii. Women       :

 

(b) Adolescents-        i. Male             :               

                                                ii. Female       :

 

(c) Children  -             i. Male             :

                                                ii. Female       :

 

9.         Number  of days  worked during

            the half-year ending 30th June,

            19…../31st December , 19....           :

 

Signature of  Manager          :    

Date                                        :

 

Explanatory Note :-

 

The average daily number should be calculated by dividing the aggregate number of  attendance on working days  by the number of  working  days  during  the  half-year. In reckoning attendance, attendance  by temporary as well as permanent employees  should  be counted,  and  all employees should be included,  whether   they  are  employed directly or under contractors.

 

Attendance  on separate shifts (e.g., night and day shifts)  should  be  counted  separately. Days  on which the  factory was closed,  for whatever  cause, and days on which the manufacturing  processes  were  not  carried  on  should not be treated as  working  days.   Partial attendance for less than half a shift  on a working day  day should be ignored, while attendance for a half a shift or more on such day  should be treated as full attendance.


 

*****************************************************************************

 

FORM - 31

 

Prescribed  under  Rule  129

 

MUSTER ROLL

 

Name of factory…………………………… Place …..……………. District………………..

Serial No.

Name of worker

Father’s Name

Nature of work

Daily attendance for month of ………………………... 19…..

Dates

Remarks

1

2

3

4

5

6

7

8

9

..

..

..

..

..

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**********************************************************************************************************************************

FORM - 32

Prescribed under Rule 130

REGISTER OF ACCIDENTS AND DANGEROUS OCCURRENCES

 

Name of

Injured person

(if any)

Date of

Accident or

dangerous

occurrence

Date of report

(in Form 25)

to Inspector

Nature of accident            or dangerous occurrence

Date of return of injured Person

to work

Number of days the injured

Person was absent from work

1

2

3

4

5

6