Form XVII

[See rule 72(5) r/w rule 74 ]

ANNUAL RETURN

FOR THE YEAR …….ENDING 31st December.

Instructions for filling up the Annual Return

(1) This return shall be filled-up and furnished on or before the 28th or 29th day of February every year.

(2) This return consists of two parts i.e. Part-I , which shall be filled up by all establishments.

(3) Part-II shall be filled-up only by the establishments that are Mines in addition to Part-I.

(4) The terms “establishment” and “mines” shall have the same meanings as assigned to them in the Occupational Safety, Health and Working

Conditions Code, 2020.

(5) This return shall be filled-up in the case of contractor or manpower supplier who has engaged more than 50 workers and in the case of mines,

even where one worker was employed during the relevant period.

Applicable to All Establishments - Part-I

A. General Information:

Sl. No. Instructions for filling the column

1. Labour Identification Number EPFO, ESIC, MCA, MoLE (LIN)

2. Period of the Return From - To- Period should be calendar year

3. Name of the Establishment

4. Email ID (employer)

5. Telephone No. (employer)

6. Mobile number (employer)

7. Premise name

8. Sub-locality

9. District

10. State

11. Pin Code

12. Geo Co-ordinates

B(a). Hours of Work in a day

B(b). Number of Shifts

Number of hours in a shift

C. Details of Manpower Deployed

Details Directly employed Employed through Contractor Grand

Total

Skill Category HighlyS Skilled Semi- Un- Highly Skilled Semi- Un-

killed Skilled Skilled Skilled Skilled Skilled

(i) Maximum No. of employees M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T

employed in the establishment in any

day during the year

(ii) Average No. of employees No. to be M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T

employed in the establishment during indicated

the year

(iii) Maximum number of Migrant Worker M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T

during the year

(Section 59 of OSH&WC Code)

(iv) Number of fixed term employee M/F/T M/F/T M/F/T M/F/T

engaged

D. Details of contractors engaged in the Establishment:

Sl. No. Name with LIN of the Contractor No. of Contract Labour Engaged

E. Details of various Health and Welfare Amenities provided.

Sl. Nature of various welfare amenities provided Statutory (specify the Instructions for filling

No. statute)

1. Whether facility of Canteen provided (as per Tick yes or no in the box Applicable to all establishments wherein hundred or more

section24(v) of OSH&WC Code, 2020) and not applicable worker including contract labour were

ordinarily employed

2. Crèches(as per section 67of Code on Social Security Tick yes or no in the box Applicable to all establishments where fifty or more

Code, 2020 and section 24 of the OSH&WC Code 2020) and not applicable workers are employed

2a If 2 above is not given than whether Crèches allowance Tick yes or no in the box Reference rule.. on Social Security

under Rule.. of Social Security Code given. and not applicable

3. Ambulance Room(as per section 24(2)(i) of OSH&WC Tick yes or no in the box Applicable to mine, building or other construction work

Code, 2020) and not applicable wherein more than five hundred workers are

ordinarily employed

4. Safety Committee (as per section 22(1) of OSH&WC Tick yes or no in the box Applicable to establishments and factories employing 500

Code, 2020. and not applicable workers or more, factory carrying on hazardous process and

BOCW employing 250workers or more,

and mines employing 100 or more workers.

5. Safety Officer (as per section 22(2) of OSH&WC Code, No. of safety officers In case of mine100 or more workers, in case of

2020) appointed

BOCW 250 or more workers and in case of dock work 500

or more workers are ordinarily employed.

6. Qualified Medical Practitioner (as per section12 No. of Qualified Medical There is no specification for minimum number of Qualified

(2) of OSH&WC Code 2020. Practitioner appointed. Medical Practitioner employed in establishment. However,

this detail is required to have

data on occupational health.

F. The Industrial Relations: Instructions for filling

1. Is the Works Committee has been functioning.(Section 3 of IR Code, Yes/No and not applicable Industrial establishment in which 100 or

2020) more workers are employed

(a) Date of its constitution.

2. Whether the Safety Redressal Committee constituted (Section 4 of IR Yes/No and not applicable Industrial establishment employing 20

Code, 2020) or more workers

3. Number of registered Unions in the establishments.

4. Whether any negotiation union exist(Section14 of IR Code,2020) Yes/No

5. Whether any negotiating council is constituted (Section 14 of IR Code, Yes/No

2020)

6. Number of workers discharged/dismissed, retrenched or whose services were terminated during the

year:

Dismissed Retrenched Discharged /Terminated or Grand

Removed Total

7. Man-days lost during the year on account of

Sl. Reasons Period No. of man-

No. /Date days lost

(a) Strike

(b) Lockout

8. Details of retrenchment / lay off

Sl. No. of persons Details of payment No. of workers No. of man-days lost due to lay-off Applies on industrial establishment

No. retrenched during paid to retrenched laid off during employing 300 or more workers

the period employees the period

G. Details pertaining to maternity benefit:

No. of female No. of female employees No. of female employees No. of deduction of wages, if any made

employees availed maternity leave paid medical bonus from female employees

H. Details of payment of bonus:

Sl. No. of employees covered under Total amount of bonus actually paid Date on which the Bonus paid

No. the Bonus provision

I. Details of accidents, dangerous occurrence and notifiable diseases:

Sl. Total number of accidents by which Total number of fatal accidents and Total number of Dangerous Total number of cases of

No. a person injured is prevented from names of the deceased as per Section Occurrences as defined under Notifiable Diseases specified

working for a period of 48 hours or 10 of the OSH&WC Code, 2020. Section 11 of the OSH&WC in Third Schedule of the

more as per section 10 of the Code,2020 OSH&WC Code, 2020 along

OSH&WC Code, 2020. with

the details of affected persons

J. Man days and production lost due to accidents / dangerous occurrences

Sl. Accident/Dangerous Man days lost Production Lost

No. Occurrence

[See rule 72 r/w rule 74]

Part II (For Mines)

A. General information

1. Establishment Name

2. Name of Company/ Name of Owner

3. Type of organization (drop down) PSU Central/ PSU State/ Private/

4. Type of ownership (drop down) Firm/Association/Individual/Partnership/Company

5. Type of Mineral (drop down) Coal/Metal/Oil

6. Name of Mineral

7. Type of Mine (drop down) Belowground/ Opencast/ Aboveground/Mixed/OffShore/OnShore

8. Date of opening To be filled for first time

9 Mine Code To be filled for first time

10. Date of closing (if any) NA/ Calendar to be given

11. Date of reopening (if any) NA/ Calendar to be given

12. Depth of working in mts. Maximum Depth: Minimum Depth:

B. Statutory personnel employed in the mine (as on 31st December)

Sl. No. Designation as per Code Number of Statutory Persons required Number of Statutory Persons employed

1.

C. Method of Working vis-a-vis Safety Parameters

1 Name of Method (Specify the name) (as per drop down menu)

2 Quantity of mineral Produced in Cu.m./Tonne

3 Quantity of Waste/overburden removed in Cu.m./Tonne

4 Stage of Working (as per drop down menu) Development/Extracti

on/Mixed

5 Permissible Void in Cu.m. For extraction stage

6 Actual Void in Cu.m. For extraction stage

7 Area of overhang For extraction stage

8 Maximum Inflammable gas released in Cu. Meter per ton of coal produced For Development

stage

9 Overall Pit slope For Opencast mines

Individual entry for each Pit

10 Overall dump slope For Opencast mines

Individual entry for each Dump

11 Area of fire in Sq. m.

12 Length of embankment required to be provided against the water body

13 Length of embankment provided against the water body

14 Length of fencing required/provided as per statute

15 No. of opening required to be sealed in case of abandoned mines:

16 No. of Openings sealed in case of abandoned mines:

17 Number of Mock drills conducted and date of same with coverage of employees

18 No. of Oil/Gas wells: under drilling/ under production/ under work over (as per drop For Oil and gas

down menu) mines

19 No. of wells where production discontinued For Oil and gas

mines

20 If Yes to pt. 19 above, Action taken

21 Action Taken in respect of Wells where production has been discontinued For Oil and gas

mines

22 Maximum Quantity of explosive used in any day (in Kgs.) For all types of mine

23 Whether Building or Structures not belonging to owner lies within danger zone? Yes/No/NA For Coal &

Metalliferous Mines

24 Aggregate HP/KW of machineries installed/deployed in the mine for the year For all types of mine

D. Medical examinations - Initial/Periodical (IME/PME):

During the year, total number of persons including contractual workers:

Particulars Total No. of Persons

Undergone IME

Undergone PME

Declared medically Temporary unfit

Given alternate Employment due to Medical unfitness

Terminated on account of being medically unfit

E. Details of Vocational training imparted:

During the year, total number of persons including contractual workers:

Particulars Total No. of Persons

Imparted Basic Vocational Training

Imparted Refresher Training

Imparted special Training

F. Details of Accident, Dangerous Occurrence and Occupational Diseases :

(1) Details of Accidents and Dangerous Occurrences:

Sl. No. Date of No. of persons killed No. of persons Number of persons injured Nature of Mandays lost

Accidents/Dangero received Serious (Excluding Serious Bodily Occurrence

us Occurrences Bodily Injury Injury) and thereby

prevented from working for a

period of 48 hours or more

1.

(2) Details of Occupational diseases:

Sl. No Notified Disease No. of cases

1

G. Details of Safety Management Plan:

(a) Safety Management Plan Prepared: (Yes/No/NA)

(b) Date of Submission : Date

(c) Last date of review of Safety Management Plan: Date

(d ) Principal Hazards Identified:

Sl. no. List of Principal hazards Principal hazard Principal hazard not mitigated Reasons for failure to

identified Mitigation date till 31st December mitigate the same

1.

H. Mines Rescue Station: (For Belowground Mines Only)

A. For Mine: (To be filled by mine owner)

(i) Address of the Rescue Station with Geo-coordinates serving the mines;

(ii) Distance of the Rescue Station from mine opening; -----(in KM)

(iii) Whether a mine Rescue Station has been established by the mine ? (Yes/No)

Mines Rescue Station: (For Belowground Mines Only)

(For Rescue Station)

For Mine Rescue Station (To be filled by the Superintendent of the Rescue Station)

(i) Name of the owner of the mine at which the Mine Rescue Station is located:

(ii) Address of MRS:

(iii) Name of the Superintendent :

(iv) Details of the mine served by the Rescue Station:

Sl. Name of the Mines Distance of the Mine from MRS (in Kms)

No.

(v) Details of Personnel Deployed at Rescue Station;

Sl. Designation as per Number of statutory Number of statutory

No. Code persons required persons employed

(vi) Details of Equipment/Apparatus :

Sl. Type of Numbers of Equipment/Apparatus available

No. Equipment/Apparatus

required

(vii) Particulars of Emergency Attended:

Sl.No. Name of the Nature of Response Time Time taken for Rescue & Action Taken

Mine Emergency (time taken by Recovery

rescue services to

attend the

emergency)

(viii) Additional Information :

(a) Number of Rescue Rooms :

(b) Number of Rescue Trained Persons Required :

(c) Number of Rescue Trained Person available :

(d) Whether Canteen facility exist or not? ( Yes/No):

Certified that the tables are duly filled in and the information and figures furnished therein are correct to the best of my knowledge.

Signature of Employer/Occupier/Owner/Agent/Manager

Place:

Dated:

PART III

[See rule 98(9)]

ANNUAL RETURN period ending 31st December

(to be submitted by the principal employer on Shram Suvidha Portal)

1. Name of the principal employer:

2. Name of the establishment:

3. Registration number (LIN) of the establishment:

4. Details of the Contractors, wages paid, etc.:

Sl. Month Name and LIN of the Name of Maximum Amount Date of Amount of Date of Remarks

address of contractor the work number of paid against payment of the wages payment of

the contract wage bill (if wage bill paid directly wages paid

contractors labour applicable) (if to the directly to

employed to the applicable) contract the contract

contractor labour by labour by

(including Principal Principal

EPF, ESIC, Employer Employer

Bonus etc.) (in case the (in case the

contractor contractor

fails to pay) fails to pay)

Signature of the principal employer

Date:

PART IV

(see rule 72(8))

Shram Shuvidha Portal

Ministry of Labour and Employment

Self-Declaration form for EPFO/ESIC Contribution Year: ___

PAN No: LIN:(Auto-Populated)

EPF Code No. (Auto-Populated)(Editable): ESI Code No.(Auto-

Branch Code Nos. (Auto- Populated)(Editable):

Populated)(Editable): Sub Code Nos. (Auto-

Populated) (Editable):

Statement of salary/wages and contribution in r/o of EPFO

1 2 3 4 =(2+3) 5 6 7 8=(5+7) 9 10 11 12=(9-10) 13

Month Total No. of Total no. of Total no. of Total Wages Total EPF Total Wages Total wages Total Total Date of Balance to No. of

& employees employees employees paid to Wages paid to paid to paid to all Contribution contribution payment be paid employees

Year eligible for not eligible employed employees employees employees employees Payable paid to whom

membership for eligible for eligible under not eligible (Based on column dues to be

under SS membership membership SS under SS 6) paid

Code/Scheme under SS under SS Code/scheme Code/scheme

Code/scheme Code/scheme

04/20..

05/20..

06/20..

07/20..

08/20..

09/20..

10/20..

11/20..

12/20.

.

01/20.

.

02/20.

.

03/20.

.

• Upload Salary sheet of contribution details of all members as per Form-VIIIB(Register of Wages, Overtime & Dedcution)

Details of Employees non-enrolled but eligible to be member:

Sr. No Name of Employee Gender Aadhaar Number Father’s Name Date of Date of Date of Exit Wages paid

Birth Joining (If already

left)

Contractors details:

S.No. Name & EPF code No. ESI Nature of Maximum Number Total payment made during the FY

Address of the code work of employees

contractor No. employed during

any day

<*contractor details may be pre-filled from CLC Licence data if available with option to add other contractors>

Details of tax benefit claimed by employer by way of contribution towards a recognized provident fund or an approved superannuation fund u/s 36(1)(iv)

of Income Tax Act:

Financial Year Contribution Tax benefit

UPLOAD DCOUMENTS:

S. No. DOCUMENT Name <upload field in portal>

1. Balance Sheet* • <upload field for Balance Sheet of the financial year>

2. Form 26AS* • <upload field for Form 26AS of the financial year>

3. Form 26Q* • <upload field for Form 26Q of the financial year>

*mandatory field

(Signature of the Employer/authorized representative)

*Section 36(1)(iv) of Income Tax Act:

any sum paid by the assessee as an employer by way of contribution towards a recognised provident fund or an approved superannuation fund, subject to

such limits as may be prescribed for the purpose of recognising the provident fund or approving the superannuation fund, as the case may be; and subject

to such conditions as the Board may think fit to specify in cases where the contributions are not in the nature of annual contributions of fixed amounts or

annual contributions fixed on some definite basis by reference to the income chargeable under the head "Salaries" or to the contributions or to the number

of members of the fund;