(NOW FORM NO.34)
(PRESCRIBED UNDER SUB-RULE (1) OF RULE 100)
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.
6. Full postal address of factory.
7. Nature of industry.
Number of workers and particulars of employment
8. No. of days worked in year.
9. NO. OF MAN-DAYS WORKED DURING THE YEAR.
10. AVERAGE NUMBER OF WORKERS EMPLOYED DAILY (SEE EXPLANATORY NOTE).
11. TOTAL NO. OF MAN-HOURS WORKED INCLUDING OVERTIME.
12. AVERAGE NUMBER OF HOURS WORKED PER DAY WORK (SEE EXPLANATORY NOTE).
13. (A) DOES THE FACTORY CARRY OUT ANY PROCESS OR OPERATION DECLARED AS DANGEROUS UNDER SECTION 87. (SEE RULE 95).
Name of the dangerous Process of operations carried on
Average No. of persons employed daily in each of the processes or operations given in Col. 1
Leave with wages
14. TOTAL NUMBER OF WORKERS EMPLOYED DURING THE YEAR.
15. NUMBER OF WORKERS WHO WERE ENTITLED TO ANNUAL LEAVE WITH WAGES DURING THE YEAR.
16. NUMBER OF WORKERS WHO WERE GRANTED LEAVE DURING THE YEAR.
17. (A) NUMBER OF WORKERS WHO WERE DISCHARGED, OR DISMISSED FROM THE SERVICE, OR QUIT EMPLOYMENT, OR WERE SUPERANNUATED, OR WHO DIED WHILE IN SERVICE DURING the year.
(b) Number of such workers in respect of whom wages in lieu of leave were paid.
(a) Number of Safety Officers required to be appointed as per notification under Section 40-B.
(b) Number of Safety Officers appointed.
19. Is there an ambulance room provided in the factory as required under Section 45 ?
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 ?
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.
(a) Total number of accidents (See explanatory note) :
(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 THE RETURN RELATES.
(i) Number of accidents.
(ii) Man-days lost due to accidents.
25 (a) Is a suggestion Scheme in operation in the factory
(b) IF SO, THE NUMBER OF SUGGESTIONS
(i) Received during the year
(ii) Accepted during the year
(c) AMOUNT AWARDED EACH PRIZES DURING THE PERIOD
(i) Total amount awarded
(ii) Value of the maximum cash prize awarded
(iii) Value of maximum cash prize awarded
Certified that the information furnished above is to the best of my knowledge and belief, correct.
SIGNATURE OF THE MANAGER
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, men-days worked) by the number of working days in the year. In reckoning attendance, attendance by temporary as well as permanent employed 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 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-season should be given separately. Similarly the number of days worked and average number of man hours 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 view 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 accident which took place during the year should be given. In case of non-fatal accidents only.