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THE FACTORIES ACT 1948

The Act has been promulgated primarily to provide saIety measures and to promote
the health and welIare oI workers employed in Iactories. Its primary aim is to
protect health and welIare oI workers employed in Iactories against industrial and
occupational hazards. Ior this purpose the Act seeks to impose upon the owners or
the occupiers certain obligations to protect workers unwary as well as negligent,
and to secure Ior them, employment conditions conducive to their health and saIety
Irom accidents. Besides, certain incidental provisions have been made Ior securing
the inIormation to ensure that the objective oI the Act is carried out.















41
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4
2

FORM NO. 1
(Prescribed under Rule 3)

Application for permission to construct, extend or take into use anv
building as a factorv.

(1) Applicant`s / Occupier`s name :
Applicant`s/Occupier`s calling :
Applicant`s /Occupier`s address :

(2) Full name and postal address oI Iactory :

(3) Situation oI the Iactory and
S.Nos./D/Nos. oI the Iactory :
State :
District :
Town or Village :
Nearest police station :

Nearest Railway Station or Steamer Ghat :

(4) Purpose Ior which plans are sent :

State whether initial approval/additional installation/additional
construction/changes in installation, etc.,

(5) II the plans have been approved earlier give the number and date oI
approval oI previous plans relevant to the present plans except in the
case oI initial approval.

(6) Details oI present proposals with reIerence to item No. 4

(7)Total installed capacity in Hors Power (including the present plans)

(8 )Maximum number oI workers proposed to be employed in the Iactory


Note :- Court Iee stamp to the value oI Rs. 1 (one) to be aIIixed in the Iirst copy
only.


Date : Signature oI applicant /
occupier



Subs.by G.O.Ms. No. 1393, Labour, dated the 2
nd
July, 1987
43
FORM NO. 2


Application for registration and grant or renewal of licence for the vear . and notice of
occupation specified in sections 6 and 7 (to be submitted in triplicate).

1. Full name oI the Iactory with Iactory licence number iI already registered
beIore. the name oI the person or persons to whom the present licence is to be
granted and issued

2. (a) Full postal address and situation oI the Iactory
(Door No. Survey No. etc.)

(b) Full address to which communications relating to the Iactory should be sent
(c) Police station in whose jurisdiction the Iactory lies.

1. Particulars oI the owner/s oI the premises or building (including the precents
thereoI reIerred to in section 93 :-

Name :

Age :

Residential address :

Father`s Name :

2. Particulars oI the Occupier oI the Iactory who has ultimate control over the
aIIairs oI the Iactory and in whose name the licence is to be issued

Please see section 2 ( n) .

Name :

Age :

Residential address :

Father`s Name :


Subs, by G.O. Ms. No. 341, Labour and Employment, dated the 22
nd
April, 1976.

44

Notes:-
1. Where the Occupier oI the Iactory is a Iirm oI other association oI individuals
or a company (please also see section 100) the above particulars should be
Iurnished in respect oI all the partners oI members oI the Iirm or association
or the directors or shareholders oI the Company.

2. In the case oI a Government or Local Fund Factory, the oIIicial designation
oI the Occupier in which name the licence is to be issued should also be
indicated.
3. Particulars oI the Manager oI the Iactory Ior the purpose oI the Act..

Name : Age: Residential address :

4. Name oI manuIacturing process/processes ..
(a) Carried on in the Iactory during the proceeding calendar year (in the case
oI Iactories already in existence) :

(b) To be carried on in the Iactory during the calendar year Ior which this
application Ior licence is made.

5. Particulars oI principal products manuIactured during the preceding calendar
year.

Sl. No. Name Value

6. (a) Particulars oI power actually installed
Sl
No
Nature oI Power Qty. in H.P.
Remarks (whether stand-
by etc.)
(1) (2) (3)

(4)

(b) Particulars oI power proposed to be additionally installed, iI any, during the
calendar year Ior which this application Ior licence is made.
Sl
No
Nature oI Power Qty. in H.P.
Remarks (whether
stand-by etc.)

(1) (2) (3)

(4)


45
(C) Maximum quantity (in HP) that can be used at any one time during the
calendar year Ior which this application Ior licence is made.

8 A. Whether the Iactory is having any pressure vessels; iI so, the number oI
pressure vessels may be indicated

8- B Whether the Iactory management had remitted Iees Ior the testing oI pressure
vessels by the notiIied persons oI Factory Inspectorate

8- C Whether the Iactory is engaged in dangerous operations as indicated under
Rule 95 oI the Tamil Nadu Factories Rules, 1950; iI so, whether the occupier oI
the Iactory has paid Iees Ior periodical medical examination oI the persons
employed, by the CertiIying Surgeon.

7. (a) Maximum number oI workers proposed to be employed on any one day
during the calendar year Ior which this application Ior licence is made )Please see
the slab limits in the Schedule to Rule 4 ).

(b) Maximum number oI workers actually employed on any one day during the
preceding calendar year.

(c) Number oI workers to be ordinarily employed in the Iactory 9 A. Number oI
calendar years Ior which grant or renewal oI license is required (indicate the
exact calendar year / years )

8. In the case oI a Iactory constructed or extended aIter the date oI the
commencement oI the rules ...

(a) ReIerence number and date oI approval oI the plans Ior site, whether Ior old or
new building, and Ior construction or extension oI Iactory by the State
Government./ ChieI Inspector.






Ins. By G.O.Ms. No. 74 Labour and Employment, dated the 19
th
June, 1996

Ins. By G.O.Ms. No. 150, Lbaour and Employment (M-11), dated the 14
th
July, 1993.


46



(b) ReIerence number and date oI approval oI the arrangements, iI any, made Ior the
disposal oI trade waste and eIIluents and the name oI the authority granting such
approval.

9. Amount oI Iee Rs. (Rupees .......... only) paid in
the Treasure/bank ...on ...vide Challan No. dated
(Demand DraIt No. date .) enclosed .

10. Tamil Nadu Labour WelIare Fund. Whether contribution to the Labour
WelIare Fund Ior the previous year has been remitted and iI so, Iurnish the
details oI amount remitted, date oI remittance, mode oI remittance (by
cheques/cash/challan




Signature oI Manager : Signature oI the Occupier :

Name in capital letters Name in capital letters



Date : Date :



....




1. Subs. By G.O. Ms. No. 149, Lab b& Emp. (M-2) dated the 26
th
July, 1995

2. Ins.by G.O.Ms. No. 2371, Labour, dated the 11
th
October, 1983.

3. Ins.by G.O. Ms. No. 1251, Lab & Emp. Dated the 19
th
October, 1978.





47

FORM NO. 3

|(Prescribed under Rule 4(4) |

Register of Factories

Registration
number
Date oI receipt
oI application
by the ChieI
Inspector oI
Factories
Number and
date oI previous
licence iI
already
registered
Name oI the
occupier and
his Iull address
Name oI the
Iactory

(1)

(2)

(3)

(4)

(5)



Situation oI the
Iactory
Total number
oI horse-power
installed
Fee paid
Name oI the
Treasure/Bank
and the Challan
Number/Demand
DraIt Number
with date.
Number and
date oI licence
issued

(6)

(7) (8) (9)

(10)






Initials oI the
Iactory


Total number oI
horse-power
installed
Initials oI oIIicer Remarks, iI any
(11) (12) (13)

(14)





Subs. By G.O. Ms. No. 149, Labour and Employment (M.2.) dated the 25
th
July, 1995.



48



FORM NO. 3-A

(Prescribed under Rule 12-A )

Notice oI change oI Manager


1. Full name oI the Iactory with current licence number

2. Full postal address

3. Name oI the outgoing Manger

4. Full name, age and Iather`s name oI the new Manager with his residential
address and telephone number, iI installed

5. Date oI appointment oI the new Manager




Date : Signature oI the new Manager


Place : Signature oI the Occupier






---------







49
FORM NO. 3-A

(Prescribed under Rule 12-A )

Notice oI change oI Manager


6. Full name oI the Iactory with current licence number

7. Full postal address

8. Name oI the outgoing Manger

9. Full name, age and Iather`s name oI the new Manager with his residential
address and telephone number, iI installed

10. Date oI appointment oI the new Manager




Date : Signature oI the new Manager


Place : Signature oI the Occupier




50

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C a l e n d a r y e r o I s e r v i c e
W a g e p e r i o d I r o m t o
W a g e e a r n e d d u r i n g t h e w a g e
p e r i o d
N o . o I d a y s w o r k r e I o r m e d
N o . o I d a y s o I l a y - o I I .
N o . o I d a y s o I m a t e r n i t y l e a v e
N o . o I d a y s o I l e a v e e n j o y e d
T o t a l o I c o l u m n s ( 4 ) - ( 7 )
B a l a n c e o I l e a v e I r o m
p r e c e d i n g y e a r
L e a v e e a r n e d d u r i n g t h e y e a r
m e n t i o n e d i n c o l u m n ( 1 )
T o t a l o I c o l u m n s ( 9 ) a n d ( 1 0 )
W h e t h e r l e a v e i n a c c o r d a n c e
w i t h s c h e m e u n d e r S e . 7 9 ( 8 )
w a s r e I u s e d
L e a v e e n j o y e d I r o m t o
B a l a n c e o I l e a v e t o c r e d i t
N o r m a l r a t e o I w a g e s
C a s h e q u i v a l e n t o I a d v a n t a g e
a c c r u i n g t h r o u g h
c o n I e s s i o n a l s s a l e o I I o o d
g r a i n s a n d o t h e r a r t i c l e s
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p e r i o d ( t o t a l o I c o l u m n s ( 1 5 )
a n d ( 1 6 )
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FORM - 17A

(Prescribed under Rule 95)

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(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)



FORM - 18

(Prescribed under Rule 96)

Report of Accident

(A separate report is to be Iilled up in respect oI each person killed or injured and each
report will constitute a separate accident. )


Tvpe of accident
Authoritv to whom report is
to be sent in this form
With in what period
(1) (2) (3)


Fatal or serious accident
likely to prove Iatal.
1. Inspector oI Factories
2. ChieI Inspector oI
Factories
3. District Magistrate or
Sub-divisional OIIicer
4. OIIice-in-charge oI the
nearest police station

With in 12 hours oI the
accident

55

Which causes such bodily
injury as prevents the
person injured Irom
working Ior a period oI 48
hours immediately
Iollowing the accident
Inspector oI Factories Within 24 hours oI the expiry
oI 48 hours aIter the
occurrence oI the accident.

1. Registration number oI the Iactory:
2. Running serial number oI the accident in the Iactory Ior the calendar year and calendar
year, 20
3. Name and address oI the Iactory:
4. Nature oI industry :
5. Name and address oI the Occupier :
6. Name and address oI the Manager :
7. Exact place in the Iactory (branch, department, machine, etc.,) where the accident
occurred :
8. Particulars oI person injured
(a) Name :
(b) Address :
(c) Sex :
(d) Age last birthday :
(e) Occupation :
(I) Monthly wages :
9. Date and hours oI accident :
10. Hours at which the person injured started work on the day oI accident :
11. Describe clearly how the accident occurred :
12. State exactly what the person injured was doing at the time oI the accident :
13. II the accident was caused by machinery
(a) Give the name and part, etc., oI the machine causing the accident :
(b) State whether it was moved by mechanical power at that time :
14. Give names and addresses oI witnesses to the accident :

56
15. Detail the nature, extent, location, etc., oI injury received.
16. Name and address oI the Doctor oI Hospital Irom whom or in which the person injured
received or is receiving treatment.
17. II the person injured has died, give :
(a) The date and hour oI his death :
(b) The date and hour oI post-mortem examination ;
(c) The name and address oI the Doctor who conducted the post-mortem examination;
and
(d) The reasons thereIore, iI no post-mortem examination was conducted
18. Any other relevant inIormation :
I certiIy that to the best oI my knowledge and belieI the above particulars are correct in
every respect.

Date oI despatch report.

Signature oI Manager (Name in BLOCK letters).
(This part is to be filled up bv the Inspector of Factories.)
R. No/Accident No. 20 Industry No.
Date oI receipt : Causation No :
Date oI investigation : Sex (M/W ; P/a):
Result oI investigation : Fatal/site oI injury :
Date oI return to work :
Minor/serious :
---------
FORM NO. 18-A
(Prescribed under Rule 96
Report of Dangerous Occurrence)
A report in this Iorm is to be sent WITHIN 12 hours oI the occurrence to ---
1. The Inspector oI Factories :
2. The ChieI Inspector oI Factories :
3. The District Magistrate, or Sub-divisional OIIicer ; and
57
FORM NO. 19
(Prescribed under Rule 97)
(To be filled in bv the Chief Inspector)

Number oI case ------ ------
Remarks ------- -------

Notice of poisoning or disease
(See introduction below)

Factory particulars ----
1. Name oI Iactory :
2. Address oI Iactory :
3. Address oI oIIice or private residence oI Occupier :
4. Nature oI Industry :
Person aIIected ---
5. Name and work number oI patient :
6. Address oI patient :
7. Sex and age oI patient :
8. Precious occupation oI patient :
9. Nature oI poisoning or disease Iorm which patient is
General particulars
10. Has the case been reported to the CertiIying Surgeon :


Dated Signature oI Factory Manager


58
FORM NO. 20 (Omitted)
--------
FORM NO. 21]
(Vide sub-rule (1) oI rules 100)
(HalI yearly return Ior the halI-year ending 30
th
June ......)
1. Registration Number oI the Factory:
2. Name and address oI the Factory:
3. name and address oI the Occupier :
4. Name and address oI the Manager:
5. Nature oI Industry:
6. Number oI days worked during the halI-year:
7. Average number oI workers employed daily:
Adults Adolescents Children
(1) (2) (3)

Male Female Male Female Male Female
8. Date oI despatch oI return:
I certiIy that to the best oI my knowledge and belieI the above particulars are correct
in every aspect.
Signature oI the Manager
(Name in BLOCK Letters)

Explanation .- Partial attendance Ior less than halI-a shiIt should be ignored and
attendance Ior halI-a-shiIt or more should be treated as Iull attendance. The average
number oI workers employed daily should be calculated by dividing the aggregate
number oI attendance on working days by the number oI working days in the halI-
year. In reckoning attendance, attendance by all employees whether employed
directly or through contractors and whether permanent or temporary should be
included: Attendance on
|
Subs by G.O.Ms.No.7, Labour and Employment (M2), dated 21
st
January, 1991.
59

Separate shiIts should be reckoned separately in arriving at the aggregate oI attendances.

The days on which the Iactory was closed Ior whatever reason and the days on which the
manuIacturing processes were not carried on, should not be treated as working days.
----
FORM No. 22
|Prescribed under sub-rule (2) oI rule 100|
Annual return for the vear ending 31
st
December .....
1. Registration number oI the Iactory
2. Name and address oI the Iactory
3. Name and address oI the Occupier
4. Name and address oI the Manager
5. Nature oI industry
NUMBER OF WORKERS AND PARTICULARS OF EMPLOYMENT
6. Number oI days worked in the year
7. Number oI man days worked during the year
(a) Men
(b) Women
(c) Children
8. Average number oI workers employed daily, (See explanatory note) including
contract workers engaged in the manuIacturing process.
(a) Adults (i) Men
(ii) Women
(b) Adolescents (i) Men
(ii) Women
(c) Children (j) Men
(ii) Women
9. Total Number oI man hours worked.
(a ) Men
(b) Women
(c) Children
Subs. By G.O.Ms. No. 245 Labour, dated the 22
nd
November, 1985 as corrected by
Errata dated the 6
th
March, 1986
60


10. Average number oI hours worked per week (See explanatory note.)
(a) Men
(b) Women
(c) Children

11. (a) Does the Iactory carry cut any process or operation declared as dangerous
under section 87 ? (See rule 95.)
(b) II so, give the Iollowing inIormation :

Name oI the dangerous processes or
operations carried on
Average number oI persons employed
daily in each oI the processes or
operations given in column (1).
(1) (2)
( i)
(ii)
(iii) Etc.
LEAVE WITH WAGES
Category oI workers

Men Women Children Total
12. Total number oI workers
employed during the year.
13. Number oI workers who were
entitled to annual leave with wages
during the year
14. Number oI workers who were
granted leave during the year
15. Number oI workers who were
discharged or dismissed Irom the service,
or quit employment, or were
superannuated or died while in service
during the year
16. Number oI such workers in respect oI
whom wages in lieu oI leave were paid
61
Particulars.
SAFETY OFFICERS
17. (a) Number oI SaIety OIIicers required to be appointed per notiIication under section
40B oI the Facto Act, 1948.
(b) Number oI SaIety OIIicers appointed
(c ) Whether notiIication has been sent to the ChieI 1 pector oI Factories in
respect oI appointments un (b) above.
AMBULANCE ROOM
18. Is the Iactory required to provide and maintain ambulance room or dispensary under
sub-section (4) section 45 oI the Act and Rule 64 ?
19. Furnish the details oI the Iacilities provided in the d pessary. The medical oIIicer/s in
charge (whether Iull till or part time, etc.) and the supporting staII.
CANTEEN
20. Is the Iactory required to provide and maintain a canteen under section 46 oI the Act..
21. Furnish the Iollowing inIormation in respect oI it canteen provided in the Iactory :-
(a) How is it run ? (by management/contractor/through co-operative basis)
(b) Does it supply
(i) Cooked Iood and reIreshment
(ii) Cooked Iood only
(iii) ReIreshment and tea only
(iv) Tea/CoIIees
(c ) Total number oI workers in the Iactory and the number oI workers patronising
the canteen
(d) Please state iI a common canteen is shared with some other Iactory

SHELTERS OR REST ROOM AND LUNCH ROOMS
22. Is the Iactory required to provide and maintain shelter/rest room and lunchroom under
section47 oI the Act iI so, Iurnish the actual number oI rest rooms/shelters/lunch
rooms provide.
62
CRECHE

23. (a) Total number oI women workers in the Iactory ?
(b) Out oI (a) above, the number oI mothers with children below the age oI 6 years
(c) Total oI such children below the age oI 6 years
24. Is the Iactory required to provide and maintain a creche under section 48 oI the Act ?
25. Is one provided and maintained as due ? iI not, why not ?
26. Where provision is made Iurnish he average daily attendance oI children at the creche
Under 2 years
Under 2 to 6 years
WELFARE OFFICERS

27. (a) Number oI WelIare OIIicers to be appointed as required under section 40 oI the
Factories Act.
(b) Number oI WelIare OIIicers appointed
ACCIDENTS

28. (a) Total number oI accidents (see explanatory note)
(i) Fatal
(ii) Non-Iatal
(b) Accidents in which workers returned to work during the year to which this return
relates --
Number of man-davs
Lost due to accidents
(i ) Accidents (workers injured) occurring during the year in which injured
workers returned to work during the same year
(ii ) Accidents (workers injured) occurring during the year in which injured workers
did not return to work during the year to which the return relates
(iii) Accidents (workers injured) occurring in the previous year in which the injured
workers returned to work during the year to which this return relates
(c ) Total number oI man days lost to the Iactory during the year

29. Date oI despatch oI this return
I certiIy that to the best oI my knowledge and belieI the above particulars are correct
in every respect

Signature of the Manager
(Name in BLOCK LETTERS)
63
Explanatory Notes
1. The average number oI workers employed daily should be calculated by dividing the
aggregate number oI attendance on working days (that is, man days worked) by the
number oI 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 ShiIt (e.g. night and day shiIts) should be counted
separately. Days on which the Iactory was closed Ior whatever cause and days on
which the manuIacturing processes were not carried on should not be treated as
working days. Partial attendance Ior less than halI a shiIt on a working day should
be ignored. While attendance Ior halI a shiIt or more on such days should be treated
as Iull attendance.

2. For seasonal Iactories, the average number oI workers employed during the working
season and the oII-seasons should be given separately. Similarly the number oI days
worked and average number oI man-hours worked per week during the working and
oII-season should be given separately.

3. The average number oI hours worked per week means the total actual hours worked
by all workers during the year excluding the rest intervals but including over time
work divided by the product oI total number oI workers employed in the Iactory
during the year and 52. in case the Iactory has not worked Ior the whole year, the
number oI weeks during which the Iactors worked should be used in place oI the
Iigure 52.

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

5. In item 28( a), the number oI accidents which took place during the year should be
given. In case oI non-Iatal accidents only those accidents, which prevented workers
Irom working Ior 48 hours or more, should be indicated











64

FORM 25

(Prescribed under rule 103)

Name and Address oI the Factory : Muster Roll :
Registration Number : For the Month oI :


S
e
r
i
a
l

N
u
m
b
e
r


N
a
m
e

o
I

t
h
e

w
o
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k
e
r

F
a
t
h
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r
`
s

n
a
m
e


D
e
s
i
g
n
a
t
i
o
n
/
n
a
t
u
r
e

o
I

w
o
r
k

Date oI birth to be
supported by
extract Irom birth
Register
P
l
a
c
e

o
I

e
m
p
l
o
y
m
e
n
t


G
r
o
u
p

R
e
l
a
y

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e
r
i
o
d
s

o
I

w
o
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k


D
a
t
e
s


1
,
2
,
3

t
o

3
1

Year Month Day
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)

-----

subs by G.O.Ms. No. 24, Lab & Emp. (M-II), dated the 12
th
February, 1993





















65

FORM NO. 25-A

|Prescribed under Rule 103 (a) |
Muster Roll of Adult Workers

Name oI Factory. Hours oI work
Place District



S
e
r
i
a
l

N
u
m
b
e
r


N
a
m
e





















o
I

w
o
r
k
e
r

G
r
o
u
p


R
e
l
a
y

S
h
i
I
t

N
u
m
b
e
r


P
e
r
i
o
d












o
I

w
o
r
k

F
i
r
s
t

p
e
r
i
o
d

S
e
c
o
n
d

P
e
r
i
o
d


T
h
i
r
d

P
e
r
i
o
d

F
i
r
s
t

P
e
r
i
o
d


S
e
c
o
n
d

P
e
r
i
o
d


T
h
i
r
d

P
e
r
i
o
d


(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)





F
i
r
s
t

P
e
r
i
o
d


S
e
c
o
n
d

P
e
r
i
o
d


T
h
i
r
d

P
e
r
i
o
d

F
i
r
s
t

P
e
r
i
o
d

S
e
c
o
n
d

P
e
r
i
o
d

T
h
i
r
d

P
e
r
i
o
d

F
i
r
s
t

P
e
r
i
o
d

S
e
c
o
n
d

P
e
r
i
o
d


T
h
i
r
d

P
e
r
i
o
d

F
i
r
s
t

P
e
r
i
o
d

S
e
c
o
n
d

P
e
r
i
o
d

T
h
i
r
d

P
e
r
i
o
d

(13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24)




F
i
r
s
t

P
e
r
i
o
d


S
e
c
o
n
d

P
e
r
i
o
d


T
h
i
r
d

P
e
r
i
o
d

T
o
t
a
l

w
e
e
k
l
y

h
o
u
r
s

U
s
u
a
l

w
e
e
k
l
y

h
o
u
r
s

N
o
r
m
a
l

d
a
i
l
y

w
a
g
e
s


O
v
e
r
t
i
m
e

p
a
y

p
a
i
d

u
n
d
e
r

s
u
b
-
s
e
c
t
i
o
n

(
1
)

o
I

s
e
c
t
i
o
n

5
9

T
o
t
a
l

a
m
o
u
n
t

p
a
i
d

R
e
m
a
r
k
s


(25) (26) (27) (28) (29) (30) (31) (32) (33)

66
Monday
Tuesday
Wednesday
Satur day Thurs day Fri day
Sunday

FORM NO. 25-H
(Prescribed under Rule 103 B)


TIME CARD For the month oI 20
(a) Name oI the Iactory and address and Registration No.
(b) Name oI the worker and his Iather`s name and ticket or token no.
(c) Designation or occupation
(d) Date oI entry into service
(e) No. oI days oI attendance during the month
(I) Signature oI the Manager

-----



Ins. By G.O. Ms. No. 1551, Labour and Employment, dated the 6
th
December, 1978
Subs. By G.O. Ms. 1766, Labour, dated the 26
th
July, 1983






















67

FORM No. 26

(Prescribed under Rule 104)
Register oI Accidents

R
u
n
n
i
n
g

s
e
r
i
a
l

n
u
m
b
e
r

o
I

t
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e

a
c
c
i
d
e
n
t

I
o
r

t
h
e

c
a
l
e
n
d
a
r

y
e
a
r

D
a
t
e

a
n
d

h
o
u
r

o
I

a
c
c
i
d
e
n
t

N
a
m
e

a
n
d

d
e
s
i
g
n
a
t
i
o
n

o
I

p
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s
o
n

i
n
j
u
r
e
d

E
x
a
c
t

p
l
a
c
e

i
n

t
h
e

I
a
c
t
o
r
y

(
B
r
a
n
c
h
,

D
e
p
a
r
t
m
e
n
t
,

M
a
c
h
i
n
e

e
t
c
)


w
h
e
r
e

t
h
e

a
c
c
i
d
e
n
t

o
c
c
u
r
r
e
d

A

I
u
l
l

c
l
e
a
r

d
e
s
c
r
i
p
t
i
o
n

o
I

h
o
w

t
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e

a
c
c
i
d
e
n
t

o
c
c
u
r
r
e
d

N
a
t
u
r
e
,

e
x
t
e
n
t
,

l
o
c
a
t
i
o
n
,

e
t
c
.
,

o
I

i
n
j
u
r
y

r
e
c
e
i
v
e
d

D
a
t
e

o
I

d
e
s
p
a
t
c
h

o
I

r
e
p
o
r
t

i
n

F
o
r
m

1
8

D
a
t
e

o
I

r
e
t
u
r
n

t
o

w
o
r
k

o
I

p
e
r
s
o
n

i
n
j
u
r
e
d
.

(1 ) (2) (3) (4) (5) (6) (7) (8)


D
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t
e

o
I

d
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p
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t
c
h

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I

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p
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t
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r

o
I

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e

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n

t
o

w
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k

o
I

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e

p
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s
o
n

i
n
j
u
r
e
d

D
a
t
e
/
s

o
I

d
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s
p
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c
h

o
I

s
u
b
s
e
q
u
e
n
t

r
e
p
o
r
t
/
s

i
n

F
o
r
m

1
8
B

N
u
m
b
e
r

o
I

d
a
y
s

t
h
e

p
e
r
s
o
n

i
n
j
u
r
e
d

w
a
s

a
w
a
y

I
r
o
m

w
o
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k

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u
m
b
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r

o
I

m
a
n
-
d
a
y
s

l
o
s
t

D
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t
a
i
l
s

o
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d
i
s
a

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m
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a
n
d

l
e
s
s

o
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e
a
r
n
i
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g

c
a
p
a
c
i
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y

i
I

a
n
y

R
e
m
a
r
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s

a
n
d

i
n
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t
i
a
l
s

o
I

M
a
n
a
g
e
r

(9 ) (10) (11) (12) (13) (14)

68
Name and address oI the
Iactory
Calendar Year Registration number oI
the Iactory

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