FORM –20A

Prescribed under Rule 101

 

REPORT OF DANGEROUS OCCURRENCE WHICH DOES NOT  RESULT IN DEATH OR BODILY INJURY

1.         Name and address of factory                      : Garima Castings # E -322 (A) , Road No.-16,VKI, Jaipur

2.         Name of occupier                                         : Vibhor V- Jain

3.         Name of manager                                         : R R Sharma

4.         Nature of industry                                          :
 
5.         Branch or department and exact
            place where the dangerous occurrence : Moulding Area
            took place                                                      :

6.         Date and hour of dangerous occurrence   : 15.12.17 , 11 Am

 
7.         Nature of dangerous occurrence During Bearing change of sand mixer machine , hammer head came out form
            (State exactly what happened                     : arm and fallon down on left hand finger & resulting minor injury.
 
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             : R R Sharma , Head Manufacturing Excellence & sustainability Management Representative
 
Date of despatch of
report                               :

(To be completed by the Inspector of Factories)

District                                    :                        Date of receipt                     :
 

Number of the Causation      : One

dangerous occurrence         : Arm & hammer fitment not checked before use and periodically.
 

Date of investigation            :
 

Result of investigation         :