(b) Mr…………………………………………..

From………………….. To…………………………………

(c) Mr…………………………………………..

Fro ………………….. To…………………………………

Serial No. Works No. Name of Sex Age (last Date of Date of
Workers birth day) employ- leaving or
ment of transfer to
present other work
work
1 2 3 4 5 6 7

Reason for Nature of job or Raw material or by Date of medical

leaving, transfer occupation product handled examination by Certifying
or discharges Surgeon
Result of Medical
Examination
8 9 10 11

Note: - 1. Column 8 - Detailed summary of reason for transfer or discharge should

be stated.

2. Column 14 - Should be expressed as fit/unfit/suspended.

If suspended from Certified fit to If certificate of Signature with date of

work, state period resume duty on unfitness or Certifying Surgeon
of suspension with with signature of suspension if
detailed reason Certifying Surgeon issued to worker.

12 13 14 15

Form No. 21

(Prescribed Under Rule 103)

Report Of Accident Including, Dangerous Occurrence Resulting In Death Or Bodily Injury

ESIC Employer's Registration No……………………………….

Code No. ……………………………….

Name and address of local Licence No. …………………………………..

ESIC office (As given in the licence)

1. Name and address of factory

2. Name, address and telephone

number of the occupier

3. Nature of Industry
(As given in the Licence)

4. Date, shift and hour of accident

or dangerous occurrence

5. Department section and exact

place where the accident or
dangerous occurrence took place

6. (a) Describe briefly how the accident

or dangerous occurrence took place

(b) Did it involve Explosion……………………… Fire………………………….

Emission of toxic Substance(s)
substance(s) ………………………………emitted……………………………………

7. Give the total number of

persons injured / killed

Number of persons injured Number of persons killed

Inside the factory *Outside the factory Inside the factory *Outside the factory

8. Name and address of witnesses 1.

2.

9. Cause of accident or dangerous occurrence

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

Signature of Manager/Occupier

Date : Name (In block letters)

Address and Telephone number

Note :- 1. *If in any accident / dangerous occurrence, persons outside the factory premises
are injured or killed please furnish the information to the extent available.
 2. Details regarding injury and persons injured / killed should be supplied in the
format given in the Annexure.

(To be completed by the Inspector of Factories)

1. Date of receipt of the report

2. District

3. (a) Number allotted to

accident involving injury
and/or liability

(b) Number allotted to dangerous

occurrence involving reportable
injury and/or fatality

4. Date of investigation

5. Classification of accident

(a) Cause wise (Give code)

(b) Industry wise (Give *NIC Code)

(c) Dangerous operation wise

(Give schedule number
under Section 87)

(d) Hazardous process-wise

section 2(cb)

(e) Occupation wise

(NCO-code Number)

6. Result of investigation

7. Remarks, if any

Signature of the Inspector

Name (in block letters)
Date……………………………

*National Industrial Classification (NIC)

Annexure

Particulars of Persons Injured, Killed

1. Particulars of injured/killed person

(a) Name

(b) Age
 (c) Sex

(d) Serial Number in the register

of adult workers

(e) Address

(f) Precise occupation

(g) Nature of job

2. Cause of injury Explosion…………………………………Fire……………………………..

Emission of Toxic substance …………………………… Others ………………………….
(Please specify)

3. Particulars of injuly

(a) Fatal (time and date of death)

(b) Non-fatal (If serious, give the extent

of injury such as loss of limb/sight
& hearing, fracture, permanent
impairment, severe burns)

(c) State whether the injured person was

disabled for more than 48 hours.

(d) Location of injury (i.e. part of body

such as right leg, left hand, left eye,
etc. injured)

4. (a) State exactly what the injured person

was doing at the time of accident or dangerous occurrence.

(b) Does this work fall in the category of hazardous/

dangerous process or operations
(please tick mark ( ) in the box.
Hazardous

process ………………………………

Dangerous

process/operation ……………………

5. (a) Hour at which the injured

person started work in the day
of accident or dangerous occurrence.

(b) whether wages in full or part are payable

to him for the day of accident or dangerous
occurrence.

6. 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 and from his place
of work

(b) the injured person 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 :

(d) the vehicle is being/not being

operated in the ordinary course of
public transport service.

7. In case the accident took place while

meeting emergencies, state:-

(a) its nature; and

(b) Whether the injured person at the

time of accident was employed for
the purpose of his employer's trade
or business in or about the premises
at which the accident took place

8. (a) Physicians, dispensary or hospital

from whom or in which injured person
received or is receiving treatment,

(b) Name of dispensary/panel doctor selected

by the insured person.

Form No.21A

(Prescribed Under Rule 103)

Report Of Dangerous Occurrence Which Does Not Result In Bodily Injury

Registration Number
Licence Number
*NIC Code Number
(As given in the licence)

1. Name and address of factory

2. Name, address and telephone

number of the occupier

3. Name of the Manager

4. Nature of Industry
5. Department, Section and exact
place where the dangerous
occurrence took place.

6. Date, shift, and hour of dangerous

occurrence.

(a) Type of dangerous occurrence

(See overleaf)

(b) Did it Involve Explosion …………………………… Fire

Emission of Toxic/
Flammable/Explosive
Substance(s)
Substance(s) emitted…………………………………..

8. 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
Date : Name (in block letters)
Address and Tele. No.

(To be completed by the Inspector of Factories)

1. Date of receipt of the report

2. District

3. (a) Number allotted to the dangerous

occurrence not involving injuries and/or death

(b) Number allotted to "Major accident" not involving

reportable injuries and/or death

4. Date of investigation

5. Cause

6. *NIC Code (As given in the licence)

7. Result of investigation.

Schedule

The following classes of dangerous occurrence, whether or not they are attended by personal
injury or disablement :-

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 in raising or lowering
person 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 where a cotton opener is used.

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.

*National Industrial Classification (NIC)

Form No. 22

(Prescribed Under Rule 104)

Notice of Poisoning Or Disease

(See Instructions Reverse)*

1
ESIC Employer's Registration No. ………………………………………….

Code No………………………….. Licence No. ………………………………………………….

2
Name and address of the NIC Code No. …………………………………………….
injured person……………………… (As given in the licence)

Local ESIC Office…………………..

1. Name and address of factory

2. Name, address and telephone

number of the occupier

3. Nature of Industry

4. Particulars of affected worker:-

(a) Name

(b) Age

(c) Sex

(d) Serial number as per Register

of Adult/Child worker

(e) Address

(f) Precise occupation

(g) Nature of job

5. Nature of poisoning/disease (Give

serial number and name as per