My Suru Safety Awards

53rd National Safety Day Celebration –4thMarch 2024
PROFORMAS
MYSORE REGION SAFETY AWARDS – 2024
Index Sheet for Safety Awards - Factories
Proforma Page
Category
Number No.
1 Best SmallIndustries (up to 100 workers) 3–8
2 Best Medium Industries (from 101 to 500 9–15
workers)
3 Best Large Industries (from 501 to 1000 workers) 16–22
4 Best Mega Industries (above 1000 workers) 23–29
5 Best Oil (Petro Chemical) Industries 30–36
6 Best Garment Industries 37–43
7 Best Worker–Female 49–51
Small Industries (up to 100 workers)

8 Best Worker–Male 52–54
Small Industries (up to 100 workers)

Medium Industries (from 101 to 500 workers)

Medium Industries (from 101 to 500 workers)

Large Industries (from 501 to 1000 workers)

1
Large Industries (from 501 to 1000 workers)
Mega Industries (above 1000 workers)

Mega Industries (above 1000 workers)

Oil Industries (Petro chemical)

Oil Industries (Petro chemical)

Garment Factories
Garment Factories
Construction Projects
Construction Projects
21 Best Safety Officer 89–94
* Proforma mandatory for all categories of factories Awards

* Proforma Formats should not be changed
2
53rdNational Safety Day Celebration – 4thMarch 2024
PROFORMA - 1
CATEGORY - SMALLINDUSTRY
(Employing upto 100 workers)
Information shall be furnished for the calendar year 2023 (01.01.2023 to
31.12.2023)
Instructions:
ü Enclose supporting documents wherever required in Support of
information furnished.
ü Separate sheets may be used to furnish the additional information.
ü Don’t delete any questions. If particular question is not applicable, then
write as “Not Applicable”.
PART A
1. General information:
1 Name and address of the Factory: :
2 Factory License Number :

(Attach latest copy of the factory
license)
3. Name of the Occupier :
Name of the Factory Manager :
Contact Number :
Email.id :
4. No. of workers ordinarily :
employed:
a) Permanent: Male : Female :
b) Contract : Male : Female :
c) Others :
(Note: attach the contract labor
license copy)
5. Brief of the manufacturing activity
carried on:
(Attach the flow chart along with
description)
6. Annual Turnover during the year :
2022-23
3
PART B
1. Details of Safety, Health & Environment Status:

SHE policy : Yes / No (enclose Copy]/NA
Safety Budget (Year-2022) : Rs.
Safety Audit (Done in the year 2022) : Yes / No (if yes, furnish details)
(Note: Please enclose all relevant documents.)
2. Accreditationsobtained in 2022&2023 (OSHAS, ISO, etc.)
Other safety awards received in 2022&2023
3. Welfare Measures:
a) Whether Rest cum Lunch Room is provided : Yes/No/NA
b) Whether Canteen facility is provided : Yes/No/NA
c) Whether Creche facility is provided :Yes/No/NA
(No. of Kids in Creche, Creche photo)
4. Overtime work:
a) Whether worker were allowed to work overtime:
b) Has exemption been granted by the dept.:
c) Rate of wages paid for Overtime work :
(Enclose copy of the overtime register for the year 2023)
5. Annual Leave with Wages:
a) Whether Annual Leave with Wages given to workers of all nature of
employment (permanent/contract/casual/daily wagesetc)(Attach the document)
6. Accident statistics for the calendar year 2023.

a) Total no. of man days worked :
b) No. of man days lost due to accidents :
c) Longest accident free period :
Accident data for the last three years
2021 2022 2023
Fatal Accidents
Serious Accidents
Reportable
Accidents
Non-reportable
Accidents
Near-miss
Accidents
Note: Submission of Combined Annual Return-2022 is compulsory (Enclose copy)
7. Safety and Health Status Reports for the year 2023:

Suggestions received Suggestions accepted Suggestions implemented
4
8. Details of machine guarding.
a) Control measures adopted to prevent accidents
b) Status report with photos.
c) Amount spent during the year 2022-23.
9. Fire Prevention.
a) Details of Fire Prevention and Control Systems provided
a. Fire extinguishers
b. Smoke detectors
c. Fire hydrant system
d. CO2 Flooding system
b) No. of fire incidents.
c) No. of persons trained in firefighting.
Permanent workers:
Contract workers :
d) Fire/Emergency Evacuation Drills records (both Announced & Unannounced) –
10. Details of safety awareness programmes:

a) No. of training programmes conducted
In-house:
Outside:
b) No. of Persons Trained in Safety:
2021 2022 2023
Permanent workers
Workers of all other
nature of employment
Percentage of workers
covered in a year
c) No. of persons deputed for training outside. Permanent/Contract
d) No. of Training Programmes conducted through Karnataka State Safety Institute
(Dept. of Factories and Boilers)
11. Details of Housekeeping.

a) Concepts adopted if any, like 5S
(Attach photographs)
12. Details of SHE Promotional Activities.

a) Safety committee. Yes / No/NA
b) Works committee Yes / No/NA
c) Worker’s participation.
[
Yes / No/NA
d) Chairman of Safety Committee (Designation)
13. a) Future action plan / commitment to promote

SHE Policy during the coming year/years.
b) Commitment to promote SHE Policy in the
5
Ancillary units/out-sourced products
14. Statutory Tests by competent person:

a) Pressure Vessels:
b) Lifting machine and tackles:
c) Power Presses:
d) Centrifugal machines:
e) Other machineries/ equipment:
f) Name of the competent person with date of such examination:
g) Is the stability of the building examined and Stability Certificate obtained:
(Attach copy of the Stability Certificate)
15. Drinking Water:

a) Source of drinking water:
b) Whether portability test conducted:
c) Periodicity of the test:
d) Agency conducting test
e) Cases of infection if any.
16. (a) Details of work-environment monitoring

Conducted with specific data and the field:
(b) Protocol for follow up action:
In case of hazardous Factories
17. Whether the On-site Emergency Plan has been prepared/updated &Approved?
18. Medical Examination/surveillance Conducted

a) No. of workers examined
Permanent workers :
Contract workers :
Others :
b) No. of Occupational Diseases identified :
c) Follow up action undertaken :
d) The name and address of the Medical Officer
Conducting such examinations
e) Copy of the Health Register in Form-16 to be furnished.
19. Whether the hazards involved in the industry along with On-site
Emergency plans have been made known to the employees, if so give
the methodology, mechanism adopted along with total number of
employees involved. Enclose copy of the relevant documents.
20. Whether the MSDS are available to all the workers in respect of all chemical
Substances, manufactured, stored, used and handled in the industry.
6
21. Is there a safety committee constituted and how often meetings are
Conducted.
22. Are the Safety Audit, Risk Analysis and Hazop Studies etc., have been
Conducted by External Agency or OISD? If so, Specify action taken for
the findings/observations of the Audit.
23. Whether Safety report has been prepared & submitted to dept. (as per
MAHC Rules).
24. Whether Preventive maintenance system is followed.
25. a. No. of on-site emergency mock-drills conducted and their

Frequency in the year 2023
b. Details of public awareness programs conducted.
26. Whether Safety Manual is prepared and Standard Operating

Procedures are developed.
Part C
Description Attach the documents
1. Special Safety training to Maintenance Training Attendance sheet, Trainer Name &
department - Electrical Safety, fall Designation, Training Photos and Contents of the
Training should be attached
protection, ladder safety, confined spaces,
hazardous energy, proper use of power
tools etc.,
Training Attendance sheet, Trainer Name &
2. PPE Training records&PPE Issue Register Designation, Training Photos and Contents of the
3. Approved Building layout plans including all

the areas.
4. Ergonomics Training program records

5. Regular Inspection & Preventive
maintenance records
6. Lack out Tag out (LOTO) Training records
7. Fire Extinguishers & Fire Alarm monthly

inspection records
8. Annual Health Check-up certificates

9. List of First Aid Boxes&First Aid Training
records
7
10. Smoke Detector installed details
11. Fire Alarm Manual call points

12. Fire Hydrant system and water storage
details along with visual fire alarm and
sprinklers details
13. List of Exit & Emergency Exits -Floor wise
details
14. Physically challenged workers documents
15. Details of Chemical Inventory &List of

Chemicals and SDS
16. Chemical handling Procedures&Chemical
Handling Training Records
17. Health & Safety Committee Meeting
Records
18. ICC or Prevention of Sexual Harassment
Committee Meeting Records
19. Fire Advisory / NOC
20. Appointment letter of Creche Staff

Additional information, if any,
Declaration
I do hereby declare that the details furnished above are true to the best of my
knowledge and belief.
Date: Signature of Occupier / Factory manager

Place: (Name in block letters)
Please Note:
Completed applications with all the necessary enclosures/documents shall be sent to:
Sri.Narendra Babu.
Joint Director of Factories,
Mysuru region.
No-1, 1st main road, Yadavagiri
Mysuru-570020.
Mob: 9663374033
Email id: hsnarendrababu@gmail.com
Last date for the submission of application: 25.01.2024.
8
53rd National Safety Day Celebration – 4th March 2024
PROFORMA - 2
CATEGORY - MEDIUM INDUSTRY

(Employing 101 to 500 workers)
31.12.2023)
Instructions:
PART A

license)
Contact Number :
Email.id :
employed:
c) Others :
license copy)
carried on:
description)
2022-23
9
PART B


Other safety awards received in 2022 &2023
d) Whether Welfare officer is appointed : Yes/No/NA
e) Whether Occupational Health Centre is provided:
f) Whether Ambulance Van is provided?
If so, provide the details
(Attach the RC Book copy, Driver driving license copy, Van Photo) :
If not, what is the alternate arrangement made?
g) Whether Factory Medical Officer with Paramedical Staff is appointed?
If so provide the details.
(Note: Please enclose copy of the relevant documents and photographs of the facility)
5. Overtime work:
employment (permanent/contract/casual/daily wagesetc) (Attach the document)

2021 2022 2023
Fatal Accidents
Serious Accidents
Reportable
Accidents
10
Non-reportable
Accidents
Near-miss
Accidents

10. Fire Prevention.
b. Smoke detectors
Permanent workers:
Contract workers :
d) Fire/Emergency Evacuation Drills records (both Announced & Unannounced) -
In-house:
Outside:
2021 2022 2023
Permanent workers
covered in a year
11
[
Yes / No/NA

ancillary units/out-sourced products
c) Power Presses:
16. Drinking Water:
b) Whether potability test conducted:

18. Whether the On-site Emergency Plan has been prepared/updated
&approved?
Permanent workers :
Contract workers :
Others :
conducting such examinations
12
substances, manufactured, stored, used and handled in the industry.
Conducted.
MAHC Rules).


Part C
tools etc.,

maintenance records

inspection records
13
7. FSSAI Certificate (Hygiene Certificate)

records
sprinklers details
details

Chemicals and SDS
Records
18. Works Committee Meeting Records
19. Grievance Handling Committee Meeting

Records
20. Details of Canteen Management

CommitteeMeeting Records
14
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
15
PROFORMA - 3
CATEGORY - LARGE INDUSTRY

(Employing 501 to 1000 workers)
31.12.2023)
Instructions:
PART A

license)
Contact Number :
Email.id :
employed:
c) Others :
license copy)
carried on:
description)
2022-23
16
PART B


h) Whether Safety officer is appointed : Yes/No/NA
5. Overtime work:

17
2021 2022 2023
Fatal Accidents
Serious Accidents
Reportable
Accidents
Non-reportable
Accidents
Near-miss
Accidents



b. Smoke detectors
Permanent workers:
Contract workers :

In-house:
Outside:
2021 2022 2023
Permanent workers
covered in a year
18


[
Yes / No/NA


c) Power Presses:
16. Drinking Water:



&Approved?
19
Permanent workers :
Contract workers :
Others :
Conducted.
MAHC Rules).


Part C
tools etc.,
20

maintenance records

inspection records

records
sprinklers details
details

Chemicals and SDS
Records

Records
21
23. Appointment letter of Welfare officers

24. Appointment letter of Factory medical officer
25. Appointment letter of Staff Nurse
26. CSR activity details
Declaration

__
_______________________________________________________
Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
‘Last date for the submission of application: 25.01.2024.
22
PROFORMA - 4
CATEGORY - MEGA INDUSTRY

(Employing more than 1000 workers)

31.12.2023)
Instructions:
PART A

license)
Contact Number :
Email.id :
employed:
c) Others :
license copy)
carried on:
description)
2022-23
23
PART B

3. Accreditationsobtained in 2022 &2023 (OSHAS, ISO, etc.)

5. Overtime work:

2021 2022 2023
Fatal Accidents
24
Serious Accidents
Reportable
Accidents
Non-reportable
Accidents
Near-miss
Accidents



b. Smoke detectors
Permanent workers:
Contract workers :

In-house:
Outside:
2021 2022 2023
Permanent workers
covered in a year
25

[
Yes / No/NA


c) Power Presses:
16. Drinking Water:



&Approved?

Permanent workers :
26
Contract workers :
Others :
Conducted.
MAHC Rules).


Part C
tools etc.,
27
maintenance records

inspection records

records
sprinklers details
details

Chemicals and SDS
Records

Records

28

26. Appointment letter of Safety officers
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
29
PROFORMA – 5
CATEGORY - OIL INDUSTRY

(Applicable to LPG / Petroleum Products (POL) Storage, Bottling / Depot,
Terminals & Refinery)
Information shall be furnished for the calendar year 2023(01.01.2023 to 31.12.2023)
Instructions:
ü Contact person from the factory for communication (Mandatory)
Name of the Manager HR Manager
Telephone No./Mobile Email ID Telephone No./Mobile Email ID
1. PART A

license)
Contact Number :
Email.id :
employed: Male : Female :
a) Permanent:
Male : Female :
b) Contract :
c) Others :
license copy)
carried on:
description)
30
2022-23
PART B

5. Overtime work:
31

2021 2022 2023
Fatal Accidents
Serious Accidents
Reportable
Accidents
Non-reportable
Accidents
Near-miss
Accidents



b. Smoke detectors
Permanent workers:
Contract workers :
d) Fire/Emergency Evacuation Drills records (both Announced & Unannounced)

In-house:
Outside:
32
2021 2022 2023
Permanent workers
covered in a year


[
Yes / No/NA


c) Power Presses:
16. Drinking Water:


33
17a.Whether the On-site Emergency Plan has been prepared/updated &Approved?

Permanent workers :
Contract workers :
Others :
Conducted.
MAHC Rules).


27. How is emergency in the idle shift, holidays managed? Whether the security
personnel are trained in emergency handling.
28. Additional information, if any,
34
Part C
tools etc.,
maintenance records

inspection records

records
sprinklers details
details

Chemicals and SDS

Records
35
Records
22. Building Structural Stability Certificate &
Building Structural Safety Inspection Report
23. Electrician / Wiremen Certificates copy

29. Do you have a Safety Work Permit
System? if so attach copy of the same

Declaration
knowledge andbelief.

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
36
PROFORMA - 6
CATEGORY - GARMENT FACTORY

31.12.2023)
Instructions:
PART A
2 Factory License Number(Attach :

latest copy of the factory license)

Contact Number :
Email.id :
employed: Male : Female :
a) Permanent:
Male : Female :
b) Contract :
c) Others :
license copy)
2022-23
37
PART B
SHE policy : Yes / No (enclose Copy]
Safety Organization : Yes / No (enclose Copy]
Safety Budget (Year2022) : Rs.
Safety Budget(Year 2023) : Rs.
Safety Officer Appointed : Yes/No (Wherever Applicable)
3. Accreditationsobtained in 2022& 2023

(OSHAS, ISO, SEDEX, WRAP, GSV, SCAN etc.)
Other safety awards received in 2022& 2023
a) Whether Rest cum Lunch Room is provided :
b) Whether Canteen facility is provided :
c) Whether Creche facility is provided
(No. of Kids in Creche, Creche photo) :
d) Whether Welfare officer is appointed :
e) Whether Ambulance Room is provided:
(Attach the RC Book copy, Driver driving license copy, Ambulance Van Photo) :
5. Overtime work:
employment (permanent/contract/casual/daily wagesetc)
[[
(Attach the document)
c) Longest accident free period
2021 2022 2023
Fatal Accidents
Serious Accidents
38
Reportable
Accidents
Non-reportable
Accidents
Near-miss
Accidents


(In specific Anemia, Canteen Workers)
Permanent workers :
Contract workers :
Others :
e) Copy of the Health Register to be furnished.


a) Details of Fire Prevention and Control Systems provided;
b. Smoke detectors
Permanent workers:
Contract workers :

In-house:
Outside:
39
2021 2022 2023
Permanent workers
covered in a year


a) Safety committee. Yes / No
b) Works Committee Yes / No
[
Yes / No
d) Authority delegated on decision making.
e) Chairman of Safety Committee (Designation)


c) Power Presses:
17. Drinking Water:


40
Part C
1. How many women workers availed
Maternity leave? Attach details
tools etc.,
4. Approved Building layout plans including all

the areas.

maintenance records

inspection records

records
sprinklers details
details
14. Pregnant workers documents

Records
41
Records
22. Building Structural Stability Certificate &
Building Structural Safety Inspection Report
23. Electrician / Wiremen Certificates copy

29. Do you have a Safety Work Permit
System? if so attach copy of the same
30. Transportation facility provided to workers
31. If workers not covered under ESI, then 3rd
party insurance coverage status
32. Cost sharing of canteen food between
management and worker
33. Canteen food nutrition value evaluated
report
34. Education allowance to workers/ workers
children
Declaration

42
Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
43
PROFORMA – 8
CATEGORY–BEST WORKER FEMALE
SMALLINDUSTRY-upto 100 workers
Information shall be furnished for the calendar year 2023 (01.01.2023 to 31.12.2023)
Instructions:
ü Only workmen and operators are eligible to apply.
(Supervisors, Engineers, Managers & Other Management Staff are not eligible to
apply)
ü The winners of the past two years are not eligible to participate.
ü Enclose supporting documents wherever required in support of statistics.
ü Separate sheets may be used to furnish additional information if any.
ü Don’t delete any questions. If particular question is not applicable, then write as “Not
Applicable”.
Telephone Email ID Telephone Email ID
No./Mobile No./Mobile
1. Name and address of the Factory and License No.:

(Attach latest copy of the factory licence)
2. Name of the worker :
3. Designation :
4. Section/Department :
5. Years of service in the factory :
6. Age of the worker :
7. Qualification :
(a) General :
(b) Technical :
8. Whether member of
44
a) Works Committee :Yes / No
b) Safety Committee : Yes / No
c) Posh Committee : Yes/No
9. Training Details:
(a) Whether trained in First Aid Treatment : Yes / No
(b) Whether trained in Fire Fighting : Yes / No
10. Training acquired in the field of safety:
a) Inhouse:
b) Outside:
11. Suggestions given to improve safety standards or to avoid accidents in the
calendar year-2023:
Detailed notes (Photos if Detailed notes (Photos if
available)of observations/Near available) of correction made to
misses made by the worker for adopt the observations made
improving the work environment by the worker.
with a view to enhance the safety,
health and welfare of the worker.
Please furnish additional documents along with the application.

12. Outstanding performance in the field of safety in the calendar year-2023:
13. Individual contribution to safety over entire service(quote the past service details)
14. Whether averted any accident during the tenure of her service:
15. Employer’s recommendation for the best worker with reasons:
16. Whether the worker has got safety award by any other reputed
Organizations. If so the details (Enclose copy of the Certificate) :
17. Whether the worker is the recipient of state level awards from the Dept. of
Factories, Boilers, Industrial Safety & Health? If so give details.
Signature of the Worker

(Name in block letters)
Date:
Place:
45
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
46
PROFORMA – 9
CATEGORY: BEST WORKER-MALE

SMALLINDUSTRY-upto 100 workers
Instructions:
apply)
Applicable”.

3. Designation :
7. Qualification :
(a) General :
47
(b) Technical :
a) Inhouse:
b) Outside:
calendar year-2023:

14. Whether averted any accident during the tenure of his service:

Date:
48
Place:
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
49
53rdNational Safety Day Celebration - 4thMarch 2024
PROFORMA – 10

CATEGORY: BEST WORKER-FEMALE
MEDIUMINDUSTRY
(From 101 to 500 workers)
Instructions:
apply)
Applicable”.

3. Designation :
50
7. Qualification :
(a) General :
(b) Technical :
c) Canteen Committee: Yes/No
d) Posh Committee: Yes/No
a) Inhouse:
b) Outside:
calendar year-2023:
improvingthe work environment by the worker.

51
Date:
Place:
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
52
PROFORMA – 11

CATEGORY– BEST WORKER- MALE
MEDIUMINDUSTRY
Instructions:
apply)
Applicable”.

3. Designation :
7. Qualification :
53
(a) General :
(b) Technical :
a) Inhouse:
b) Outside:
calendar year-2023:

54
Date:
Place:
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
55
PROFORMA – 12

LARGE INDUSTRY
Instructions:
apply)
Applicable”.

3. Designation :
7. Qualification :
56
(a) General :
(b) Technical :
d) Posh Committee : Yes/ No
a) Inhouse:
b) Outside:
calendar year-2023:

57
Date:
Place:
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
58
PROFORMA – 13

CATEGORY: BEST WORKER- MALE
LARGE INDUSTRY
Information shall be furnished for the calendar year 2023(01.01.2023 to 31.12.2023)
Instructions:
apply)
Applicable”.

3. Designation :
7. Qualification :
(a) General :
59
(b) Technical :
a) Inhouse:
b) Outside:
calendar year-2023:


Date:
60
Place:
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
61
PROFORMA – 14

CATEGORY:BEST WORKER-FEMALE
MEGA INDUSTRY
(Above 1000 workers)
Instructions:
apply)
Applicable”.

3. Designation :
62
7. Qualification :
(a) General :
(b) Technical :
d) Posh committee : Yes/No
a) Inhouse:
b) Outside:
calendar year-2023:

63
Date:
Place:
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
64
PROFORMA – 15

MEGA INDUSTRY-(Above 1000 workers)
Instructions:
apply)
Applicable”.

3. Designation :
65
7. Qualification :
(a) General :
(b) Technical :
a) Inhouse:
b) Outside:
calendar year-2023:

66
Date:
Place:
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
67
PROFORMA – 16

OIL INDUSTRY (PETRO CHEMICAL)
Instructions:
apply)
Applicable”.

3. Designation :
68
7. Qualification :
(a) General :
(b) Technical :
d) Posh Committee: Yes/ No
a) Inhouse:
b) Outside:
calendar year-2023:

69

Date:
Place:
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
70
PROFORMA – 17

OIL INDUSTRY (PETRO CHEMICAL)
Instructions:
apply)
Applicable”.

3. Designation :
7. Qualification :
(a) General :
71
(b) Technical :
a) Inhouse:
b) Outside:
calendar year-2023:
Detailed notes (Photos if available) Detailed notes (Photos if
of observations/Near misses made available) of correction made to
by the worker for improving the adopt the observations made
work environment with a view to by the worker.
enhance the safety, health and
welfare of the worker.


Date:
72
Place:
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
73
PROFORMA – 18

GARMENT FACTORY
Instructions:
apply)
Applicable”.

3. Designation :
7. Qualification :
(a) General :
74
(b) Technical :
a) Inhouse:
b) Outside:
calendar year-2023:


Date:
75
Place:
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
76
PROFORMA – 19

CATEGORY:BEST WORKER- MALE
GARMENT FACTORY
Instructions:
apply)
Applicable”.

3. Designation :
7. Qualification :
(a) General :
(b) Technical :
77
a) Inhouse:
b) Outside:
calendar year-2023:


Date:
78
Place:
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
79
PROFORMA – 20

CONSTRUCTION PROJECTS
Instructions:
apply.)
Applicable”.
ü Contact person from the construction project for communication (Mandatory)
1. Name and address of the construction project :
3. Designation :
4. Years of service in the construction site :
6. Qualification :
(a) General :
(b) Technical
7. Whether member of Safety Committee : Yes / No
8. Training Details
a) Whether trained in First Aid Treatment : Yes / No
b) Whether trained in Fire Fighting : Yes / No
c) Whether Member of Emergency Management Team : Yes/No
80
a) Inhouse:
b) Outside
calendar year-2023:

12. Individual contribution to safety over entire service(quote the past
Organizations. If so the details (Enclose copy of the Certificate)

Date:
Place:
Declaration
Date: Signature of Employer / Project manager

Please Note:
Sri.Narendra Babu.
Mysuru region.
81
Mysuru-570020.
Mob: 9663374033
PROFORMA – 21
CATEGORY: BEST WORKER-MALE

CONSTRUCTION PROJECTS
Instructions:
apply.)
Applicable”.
ü Contact person from the construction project for communication (Mandatory)
1. Name and address of the construction project :
3. Designation :
4. Years of service in the construction site :
6. Qualification :
(a) General :
(b) Technical
a) Safety Committee : Yes / No
b) Posh Committee : Yes/No
8. Training Details
a) Whether trained in First Aid Treatment : Yes / No
b) Whether trained in Fire Fighting : Yes / No
82
c) Whether Member of Emergency Management Team : Yes/No
a) Inhouse:
b) Outside
calendar year-2023:

12. Individual contribution to safety over entire service(quote the past
Organizations. If so the details (Enclose copy of the Certificate)

Date:
Place:
Declaration
Date: Signature of Employer / Project manager

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
83
Mob: 9663374033
53rdNational Safety Day Celebrations –4thMarch 2024

PROFORMA-22

CATEGORY:BEST SAFETY OFFICER
Instructions:
Information shall be furnished for the Three years 2021 - 2023 (01.01.2021 to
31.12.2023)
ü The Applicant must have worked for at least five years in the field of Occupational
Safety & Health and must have worked for at least one year as a
designated/notified Safety Officer under section 40B of the Factories Act, 1948 or
section 38(2) of the BOCW Act, 1996 and Rules made there under.
ü Enclose supporting documents wherever required to support information
Applicable”.
Name of the Factory Manager HR Manager
Telephone No./Mobile Email ID Telephone No./Mobile Email ID
1. Name and address of the Factory:

Factory Licence Number:
2. Name of the Occupier&Factory Manager :
3. Name of the Safety Officer:
a) Designation:
b) Qualification B.sc,/ Engineering / Diploma:
c) Safety Course Details:
d) No. of years of service in the existing factory as a Safety professional:
e) No. of years of service in other companies as Safety Officer:
f) Any other Certification related Safety and Health :

SHE policy : Yes / No (enclose Copy]
Safety Organization : Yes / No (enclose Copy]
84
a) Internal
b) External
Accreditations obtained in 2023 : (OSHAS, ISO, etc.)
Other safety awards received in 2022, 2023 :
a. No. of Fatal Accidents
b. No. of reportable accidents

(Non-fatal) during the year
c. No. of dangerous occurrence
d. Total no. of man days worked

e. No. of man days lost due to
accidents
f. Longest accident free period
g. Control measures adopted to

prevent accidents
6. Accident data for the last three years
2021 2022 2023

Fatal Accidents
Serious Accidents
Reportable
Accidents
Non-reportable
Accidents
Near-miss
incidents
Note: 1. Submission of Combined Annual Return-2022 is compulsory
2. Explain your role in accident reporting, investigation and analysis
in your present Factory (1,2.Enclose copies)
7. Details of Mechanism in place for reporting, analyzing and correcting in case of any
incidents.
Sl.No. Name of the Manufacturing Hazard Hazard Remidial

organisation activity indetified indetified measures
without after
accident accident
Note: Enclose detailed case study report

(Fatal/Major/Minor/Fire/Property Damage/Near Miss)
85
8. Safety and Health Status Reports:


a) No. of training programmes conducted :
1. In-house:
2. outside:
2021 2022 2023
1 No oftraining programmes organized in your
presence
2 No oftraining programmes organized with the help
of outside expert agencies
3 Permanent workers
4 Workers of all other nature of employment
5 Percentage of workers covered in a year
b) No. of persons deputed for training outside. Permanent/Contract
c) Amount spent on SHE training during the year.
(Dept. of Factories and Boilers) :
11. Plant/site safety inspections conducted by you in your present Factory/
Establishment in order to observe the physical conditions of work, work
practices and procedures followed by employees.
No. of Plant safety inspections No. of Remedial measures
Year Planned Actual Suggested Implemented
2021
2022
2023
12. Safety Audits organized / conducted by you in your present Factory/

Establishment.
Year No. of safety audits No. of points identified No. of points corrected
2021
2022
2023
86
(Attach a latest copy of executive summary of the Safety Audit report & evidence of
its implementation.)
13.Mock drills(excluding fire drill) arranged/conducted as per the

onsite emergency plan in your present Factory/ Establishment.
Explain your role in such mock drill.
Year No. of mock drill No. of points No. of revisions made
conducted observed in the Plan
2021
2022
2023
14 .Details of SHE Promotional Activities.
Sl.No Details Remarks

a. Safety committee:
i)Central Safety Committee
ii) Department wise safety Committee
b. Workers participation
i) Permanent workers
ii) Contract workers
c. Authority delegated on decision making
d Chairman of Safety Committee(Designation):
15. Furnish the following details with hard copies:
Compliance Remarks& Enclosures

Sl. No
attached
No. of Safety and Health Training conducted in
2023 including Toolbox talks, etc.,
1.
( List of Trainings conducted, and No of hours
covered per person)
EHS Digitalization - Any initiative to record online
Safety and Health Data foreasy access by all in
2.
the organization.
( If Yes, Give details.)
Safety and Health Projects Implemented to
minimize the risk.(Best/Better Practice)
3.
( Give the details of Projects highlighting improvement
in Safe working Environment- Before & after.)
Any process developed to ensure compliance to
4. H&S at design stage/ standards. .
( Give Details of process)
Details of Serious accidents occurred and
actions initiated to improve safe working
5.
condition. (Give the trend of accidents for 3 yrs.)
(Also furnish Near miss / first aid case & reportable
87
accidents data for 3 years)
Safety Culture Improvement: -Initiatives taken for
conducting Safety Culture survey to improve
6. EHS performance and implementation of BBS
program
( If Yes, give the details.)
Any Safety and Health Recognition for Company
7. received by any other reputed Organizations
( If so the details (Enclose copy of the Certificate)
Whether the Safety officer was recognized by any
8. other reputed Organizations.
( If so the details (Enclose copy of the Certificate))
Initiatives implemented to involve employees in
9. safety activities
( Give Details)
Details of system developed for Handling of H&S
10. Failures, Defects and Anomalies.
Details of noncompliance notices received from

11.
legal authorities on EHS issues
No. of safety inspections, Risk assessments,
12. Safety committee meetings conducted & Follow
up actions
Explain your contribution in Hazard Identification
& Risk Assessment using technique like HAZOP,
JSA, QRA, etc. in your present Factory/
13.
Establishment
( Give Details)
Detailsof SafetyPromotional activities like

campaigns competitions, exhibition etc.,
organized/conducted in your present Factory/
14.
Establishment
(Attach copy of celebration report with photo
evidence)
Has your Factory/Establishment won any
National/state/local level safety awards during
15. your tenure as safety officer?
(Give Details)
16. Any achievement worth mentioning in your entire service
17. Explain in brief why you should be awarded as best safety officer with
emphasized performance and your vital role contributed to accomplish the
best safe practices in your organization:
18. Management’s recommendation for the best Safety Officer with reasons:
Signature of the Safety Officer

88
Date:
Place:
Declaration

Please Note:
Sri.Narendra Babu.
Mysuru region.
Mysuru-570020.
Mob: 9663374033
89
90

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53rd National Safety Day Celebration –4thMarch 2024

Index Sheet for Safety Awards - Factories

Small Industries (up to 100 workers)

Small Industries (up to 100 workers)

Medium Industries (from 101 to 500 workers)

Medium Industries (from 101 to 500 workers)

Large Industries (from 501 to 1000 workers)

Mega Industries (above 1000 workers)

Mega Industries (above 1000 workers)

Oil Industries (Petro chemical)

Oil Industries (Petro chemical)

* Proforma mandatory for all categories of factories Awards

2 Factory License Number :

1. Details of Safety, Health & Environment Status:

6. Accident statistics for the calendar year 2023.

7. Safety and Health Status Reports for the year 2023:

10. Details of safety awareness programmes:

11. Details of Housekeeping.

12. Details of SHE Promotional Activities.

13. a) Future action plan / commitment to promote

14. Statutory Tests by competent person:

15. Drinking Water:

16. (a) Details of work-environment monitoring

In case of hazardous Factories

18. Medical Examination/surveillance Conducted

24. Whether Preventive maintenance system is followed.

25. a. No. of on-site emergency mock-drills conducted and their

26. Whether Safety Manual is prepared and Standard Operating

3. Approved Building layout plans including all

4. Ergonomics Training program records

6. Lack out Tag out (LOTO) Training records

7. Fire Extinguishers & Fire Alarm monthly

8. Annual Health Check-up certificates

11. Fire Alarm Manual call points

14. Physically challenged workers documents

15. Details of Chemical Inventory &List of

19. Fire Advisory / NOC

20. Appointment letter of Creche Staff

Date: Signature of Occupier / Factory manager

Last date for the submission of application: 25.01.2024.

CATEGORY - MEDIUM INDUSTRY

2 Factory License Number :

SHE policy : Yes / No (enclose Copy]/NA

3. Accreditationsobtained in 2022&2023 (OSHAS, ISO, etc.)

7. Accident statistics for the calendar year 2023.

8. Safety and Health Status Reports for the year 2023:

Suggestions received Suggestions accepted Suggestions implemented

9. Details of machine guarding.

14. a) Future action plan / commitment to promote

In case of hazardous Factories

25. Whether Preventive maintenance system is followed.

1. a. No. of on-site emergency mock-drills conducted and their

2. Whether Safety Manual is prepared and Standard Operating

3. Ergonomics Training program records

5. Lack out Tag out (LOTO) Training records

6. Fire Extinguishers & Fire Alarm monthly

8. Annual Health Check-up certificates

13. Physically challenged workers documents

14. Details of Chemical Inventory &List of

18. Works Committee Meeting Records

19. Grievance Handling Committee Meeting

20. Details of Canteen Management

21. Fire Advisory / NOC

22. Appointment letter of Creche Staff