Form XII

{SeeRule-32(5)(a), Rule-76}

ANNUAL RETURN

FOR THE YEAR…….ENDING 31st December.

Single Annual Integrated Return to be filed On-line under the Occupational

Safety, Health and Working Conditions Code, 2020, the Code on Industrial

Relations,2020,the Code on Social Security, 2020, and the Code on Wages,

2019 and the rules made there under.

Instructions to fillup the Annual Return

1. This return is to befilled-up and furnished on or before 1st February every

year.

2. The return has two parts i.e. Part-I to be filled up by all establishments.

3. The terms Establishment and Mines shall have the same meaning as under the

Occupational Safety, Health and Working Conditions Code, 2020.

4. This return is to be filled-up incase of Contractor or manpower supplier who

have engaged more than 50 workers and incase of Mines even if there is one

worker employed in the relevant period.

Applicable to All Establishments-Part-I

A. General Information:

Sl. No. Instructions for filling the column

1. Labour Identification EPFO ,ESIC, Registration

Number number,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. Telephon 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 Gran

Contractor

d

Total

Skill Category Highly Skill Semi- Un- Highly Skill Semi- Un-

Skillede d Skilled Skill Skilled ed Skilled Skill

ed ed

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

employees employed T T

in the establishment

in any day during

the year

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

employees employed be T T

in the establishment indicate

during the year

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

of Migrant Worker T T

during the year

(Section 59 of OSH

Code)

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

term employee

engaged

D. Details of contractors engaged in the Establishment:

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

the Contractor

E. Details of various Health and Welfare Amenities provided.

Sl.No Nature of various welfare Statutory Instructions for filling

amenities provided (Specify the

statute)

1. Whether facility of Canteen Tick yes or Applicable to all establishments

provided(as per section24(v) of no in the box where in hundred or more

OSH Code, 2020) and not worker including contract labour

applicable

were ordinarily employed

2. Crèches (as per section 67of Tick yes or Applicable to all establishments

Code on Social Security no in the box where fifty or more workers are

Code,2020 and Section 24 of and not employed

applicable

the OSH Code 2020)

2(a) If 2 above is not given than Tick yes or Reference rule..on Social

whether Crèches allowance no in the box Security

and not

under Rule..of Social Security

applicable

Code given.

3. Ambulance Room (as per Tick yes or Applicable to mine,building and

section24(2)(i)of OSH Code, no in the box other construction

2020) and not Work wherein more than five

applicable hundred workers are ordinarily

employed

4. Safety Committee (as per Tick yes or Applicable to establishments

Section 22(1)of OSH Code, no in the box

and factories employing 500

2020. and not

workers or more,factory

applicable

carrying on hazardous

Process and BoCW employing

250 workers or more, and mines

employing 100 or more workers.

5. Safety Officer (as per Section No.of In case of BOCW 250 or more

22(2)of OSHCode, 2020) safety workers are ordinarily

employed.

officers

appointed

6. Qualified Medical Practitioner No. of There is no specific ation for

(as per Section12 (2) of OSH Qualified minimum number of Qualified

Code2020.

Medical Medical Practitioner employed

Practitioner in Establishment. However, this

appointed. detailis required tohave data

on occupational health.

F.The Industrial Relations: Instructions for filling

1. Is the Works Committee has Yes/No and not Industrial establishment in

been functioning.(Section 3 of IR applicable which 100 or more

Code, 2020) workers are employed

(a) Date of its constitution.

2. Whether the Safety Redressal Yes/No and not Industrial establishment

Committee constituted(Section4 applicable employing

Of IR Code,2020) 20 or more workers

3. Number of registered Unions in

the establishments.

4. Whether any negotiation union Yes/No

exist(Section14 of IR Code,2020)

5. Whether any negotiating council Yes/No

is constituted (Section 14 of IR

Code, 2020)

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

terminated during the year:

Dismissed Retrenched Discharged/Terminated or Grand Total

Removed

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

Sl. Reasons Period/Date No of man-days lost

No

a) Strike

b) Lockout

8. Details of retrenched /lay off

Sl. No. of Details of No.of workers No.of man- Applies on

No. persons Payment paid to laid off during days lost industrial

retrenche

retrenched employees the period due tolay- stablishment

d during

off employing

the period

300 or more

workers

G. Details pertaining to maternity benefit:

No.of female No.of female No.of female No.of deduction of

employees

employees availed employees paid wages,if any made from

maternity leave medical bonus female employees

H.Details of payment of bonus:

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

No.

covered under the bonus actually paid

Bonus provision paid

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

Sl. Total number of Total number Total number Total number of

No. accidents by which of fatal of Dangerous cases of Notifiable

a person injured is accidents and Occurrences Diseases specified

prevented from names of the as defined in Third Schedule of

working for a period deceased as under Section the OSH Code,

of 48 hours or more per Section 10 11 of the OSH 2020 along with the

as per Section 10 of of the OSH Code,2020 details of affected

the OSH Code, Code, 2020. persons

2020.

J.Man days and Production Lost due to accidents/dangerous occurrence

Sl. Accident/Dangerous Man days lost Production Lost

No. Occurrence