Form XXIII

[(See rule 53(5)]

ANNUAL RETURN

FOR THE YEAR …….ENDING 31st December

Single annual integrated return to be filed online under the Occupational Safety, Health and Working

Conditions Code, 2020(37 of 2020), the Code on Industrial Relations, 2020(35 of 2020), the Code on

Social Security, 2020(36 of 2020), and the Code on Wages, 2019(29 of 2019) and the rules made there

under.

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

respective Codes.

(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. Instructions for filling the column

N

o.

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

Identification

Number

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

Return

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

Directly employed Employed through Contractor Gran

d

Details

Tota

l

Skill HighlySkill Skille Semi- Un- Highl Skille Sem Un-

Category ed d Skille Skille y d i- Skille

d d Skille Skill d

d ed

(i) M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T

Maxim

um No. of employees employed in the establishment in any

day during the

year

(ii) No. to be M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T

Avera indicated

ge No. of employees employed in the establishment during

the year

(iii) Maximum M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T

number of

Migrant

Worker during

the year

(Section 59 of

OSH&WC

Code)

(iv) Number M/F/T M/F/T M/F/T M/F/T

of fixed term

employee

engaged

D. Details of contractors engaged in the Establishment:

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

No. Contractor

E. Details of various Health and Welfare Amenities provided.

Sl Nature of various welfare Statutory Instructions for filling

. amenities provided (specify the

No statute)

.

1. Whether facility of Canteen Tick yes or no in Applicable to all establishments wherein hundred

provided (as per section24(v) of the box and not or more worker including contract

OSH&WC Code, 2020) applicable labour were

ordinarily employed

2. Crèches(as per section 67of Tick yes or no in Applicable to all establishments where fifty or

Code on Social Security Code, the box and not more workers are employed

2020 and section 24 of the applicable

OSH&WC Code 2020)

2 If 2 above is not given than Tick yes or no in Reference rule.. on Social Security

a whether Crèches allowance the box and not

under Rule.. of Social Security applicable

Code given.

3. Ambulance Room(as per section Tick yes or no in Applicable to mine, building or other construction

24(2)(i) of OSH&WC Code, the box and not work wherein more than five hundred workers are

2020) applicable ordinarily employed

4. Safety Committee (as per section Tick yes or no in Applicable to establishments and factories

22(1) of OSH&WC Code, 2020. the box and not employing 500 workers or more, factory carrying

applicable on hazardous process and BOCW employing

250workers or more,

and mines employing 100 or more workers.

5. Safety Officer (as per section No. of safety In case of mine100 or more workers, in case of

22(2) of OSH&WC Code, 2020) officers

BOCW 250 or more workers and in case of dock

appointed

work 500 or more workers are ordinarily employed.

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

per section12 Qualified Qualified Medical Practitioner employed in

(2) of OSH&WC Code 2020. Medical establishment. However, this detail is required to

Practitioner have

appointed. data on occupational health.

F. The Industrial Relations: Instructions for

filling

1. Is the Works Committee has been functioning.(Section 3 of IR Yes/No and Industrial

Code, 2020) not applicable establishment in

which 100 or more

workers are employed

(a) Date of its constitution.

2. Whether the Safety Redressal Committee constituted (Section 4 Yes/No and Industrial

of IR Code, 2020) not applicable establishment

employing 20 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 Yes/No

Code, 2020)

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

terminated during the year:

Dismissed Retrenched Discharged Grand

/Terminated Total

or Removed

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

Sl. Reasons Period No.

No. /Date of

man-

days

lost

(a) Strike

(b) Lockout

8. Details of retrenchment / lay off

Sl. No. of persons Details of payment No. of No. of man-days Applies on industrial

No. retrenched during paid to retrenched workers laid lost due to lay-off establishment

the period employees off during employing 300 or more

the period workers

G. Details pertaining to maternity benefit:

No. of femNaole. oefm fpemloayleee s No. of female No. of deduction of wages, if

employees availed employees paid any made from female

maternity leave medical bonus employees

H. Details of payment of bonus:

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

No. under the Bonus provision actually paid

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

Sl. Total number of accidents by Total number of fatal Total number of Total number of

No. which a person injured is accidents and names of Dangerous cases of Notifiable

prevented from working for a the deceased as per Occurrences as Diseases specified

period of 48 hours or more as Section 10 of the defined under in Third Schedule of

per section 10 of the OSH&WC Code, 2020. Section 11 of the the OSH&WC Code,

OSH&WC Code, 2020. OSH&WC 2020 along with

Code,2020 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

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/Extraction/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 For

per ton of coal produced 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 For Oil and

production/ under work over (as per drop down gas mines

menu)

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 For Oil and

has been discontinued gas mines

22 Maximum Quantity of explosive used in any day (in For all types

Kgs.) of mine

23 Whether Building or Structures not belonging to Yes/No/NA For Coal &

owner lies within danger zone? Metalliferous

Mines

24 Aggregate HP/KW of machineries For all types

installed/deployed in the mine for the year 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. Date of No. of persons No. of Number of persons Nature of Mandays

No. Accidents/Dangerous killed persons injured (Excluding Occurrence lost

Occurrences received Serious Bodily

Serious Injury) and thereby

Bodily Injury 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 Principal hazard Principal hazard not Reasons for failure

hazards identified Mitigation date mitigated till 31st to mitigate the same

December

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. No. Name of the Mines Distance of the Mine from MRS (in Kms)

(v) Details of Personnel Deployed at Rescue Station;

Sl. No. Designation as per Code Number of statutory persons Number of statutory persons

required employed

(vi) Details of Equipment/Apparatus :

Sl. No. Type of Numbers of Equipment/Apparatus available

Equipment/Apparatus

required

(vi) 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)

(vii) 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

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 Mont Name LIN of Nam Maximu Amount Date of Amount Date of Remar

. h and the e of m paid payment of the payment ks

address contract the number against of wage wages of

of the or work of wage bill bill paid wages

contracto contract (if directly paid

(if

rs labour applicabl to the directly

applicabl

employe e) to the contract to the

d contracto e) labour contract

r by labour

(includin Principa by

g EPF, l Principa

ESIC, Employ l

Bonus er (in Employ

etc.) case the er (in

contract case the

or fails contract

to pay) or fails

to pay)

Signature of the principal employer

Date:

PART IV

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-Populated)(Editable): Sub Code

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

Populated)(Editable):

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

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

=(2+3) 7) 9-

10)

Mo Total Total Tota Total Total Total Tota Total Total Da Bal No.

nth No. of no. of l no. Wages EPF Wages l Contr contri te anc of

& emplo emplo of paid to Wages paid to wag ibutio bution of e to empl

Ye yees yees empl employ paid to emplo es n paid pay be oyee

ar eligibl not oyee ees employ yees paid Payab me pai s to

e for eligibl s eligible ees not to all le nt d who

memb e for empl for eligibl eligibl empl (Based m

ership memb oyed membe e e oyee on dues

under ership rship under under s column to be

SS under under SS SS 6) paid

Code/ SS SS Code/s Code/s

Sche Code/s Code/s cheme cheme

me cheme cheme

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. Name of Gender Aadhaar Father‘s Date Date Date of Wages paid

No Employee Number Name

of of Exit(If

Birth Joining already

left)

Contractors details:

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

Address No. code of Number of

of the No. work employees

contractor 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;