Form XIII

[See clause 5 (a) and 5 (b) of Rule 28]

Unified Annual Returns

ANNUAL RETURN

FOR THE YEAR……. ENDING 31st December 20

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, 2 020 (35of2020), 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 to fill up the annual return

1. This return is to be filled-up and furnished on or before 1st February

every year.

2. There turn has three parts i.e. Part-I to be filled up by all

establishments.

3. Part-II to be filled-up by the establishments who are a mine only.

4. The term establishment and mines shall have the same meaning as

under the respective Codes.

5. Part-III is to be submitted by the principal employer on Shram

Suvidha Portal.

Applicable to All Establishments -Part-I

A. General Information:

Sl. No. Instructions for filling the column

1. Unique ID

Number

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

Return To -

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 Gran

Con tractor d

Total

Skill Category High SkilleSem Un- Hig SkillSe Un-

lySki Skill hly mi- Skill

d i- ed

lled ed Skil Skil ed

Skill

led led

ed

(i)Maximum No. Of

M/F/T M/F/ M/F M/F/ M/F/ M/F M/F/ M/F

employee’s employed

T /T T T /T T /T

in the establishment in

any Day during the

year

(ii)Average Number of

No. To M/F/ M/F M/F/ M/F/ M/F M/F/ M/F

employees employed

be T /T T T /T T /T

in the establishment

indicat

during the year

ed

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

of Migrant Worker T /T T T /T T /T

during the year

(Section59 of OSH

Code)

(iv)Number of fixed

M/F/T M/F/ M/F M/F/

term employee engaged

T /T T

D. Details of contractors engaged in the establishment:

Sl. No. Name with Unique ID of No. of Contract Labour Engaged

the Contractor

E. Details of various health and welfare amenities provided.

Sl. Nature of various Statutory Instructions for filling

No. welfare amenities (specify the

provided statute)

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

Canteen provided (as no in the wherein hundred or more worker

per section 24(v) of box and not including contract labour were

Occupational safety, applicable ordinarily employed

health and working

Conditions Code, 2020)

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

67of Code on Social no in the where fifty or more workers are

Security, 2020 and box and not employed

Section 24 of the applicable

Occupational safety,

health

And working conditions

Code, 2020)

2a If 2 above is not given Tick yes or Reference rule 39 of the Code on

then whether Crèches no in the Social Security (Central) Rules,

allowance under rule box and not

2025.

39 of the Code on applicable

Social Security

(Central) rules, 2025

given.

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

per section 24(2)(i) of no in the other construction work where in

Occupational safety, box and not more than five hundred workers

health and working applicable are ordinarily employed

conditions Code,2020)

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

per Section 22(1) of no in the factories employing 500 workers or

Occupational safety, box and not more, factory carrying on

health and working applicable hazardous process and BoCW

conditions Code, 2020. employing 250 workers or more,

and mines employing100 or more

workers.

5. Safety Officer (as per No. of safety In case of mine100 or more

Section 22(2) of officers workers and in case of Dock

Occupational safety, Appointed Work 500 or more workers and

health and working in case of BOCW 250 or more

conditions Code, 2020) workers are ordinarily employed.

6. Qualified medical No. of There is no specification for

practitioner (as per Qualified minimum number of qualified

section12 (2) of medical medical practitioner employed in

Occupational safety, practitioner establishment. However, this

health and working appointed. detail is required to have Data on

Conditions Code, occupational health.

2020.

F. The Industrial Relations: Instructions for

filling

1. Is the works committee has been Yes/No and Industrial

functioning. (section3 of Code on not applicable establishment in

Industrial Relations, 2020) which 100 or more

workers are

employed

(a) Date of its constitution.

2. Whether the Grievance Redressal Yes/No and Industrial

Committee constituted (Section 4 of not applicable establishment

Code on Industrial Relations, 2020) employing 20 or

more workers

3. Number of registered Unions in the

establishments.

4. Whether any negotiating union Yes/No

exist(Section14 of Code on Industrial

Relations, 2020)

5. Whether any negotiating council is Yes/No

constituted (Section 14 of Code on

Industrial Relations,

2020)

6. Number of workers discharged/dismissed,

retrenched or whose services were terminated

during the year:

Dismissed Retrenched Discharge Grand

d/ Term Total

inated or

Removed

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

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

No.

lost

(a) Strike

(b) Lockout

8. Details of retrenchment /layoff

Sl. No. of persons Details of No. of No. of Applies on

No. retrenched payment workers laid man- industrial

during the paid to off during establishment

days lost

period retrenched the period employing 300 or

due to

employees more workers

lay-off

G .Details pertaining to maternity benefit:

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

female Employees employees deductio

employees availed paid medical n of

bonus

maternity leave wages,

if any

made from

female

employees

H. Details of payment of bonus:

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

No. covered under the amount of

Bonus provision bonus

actually paid

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

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

No. accidents by which a number of of Notifiable diseases

person injured is fatal Dangerous specified

prevented from working accidents Occurrences

for a period of 48 hours and names as defined In Third Schedule of the

or more as per of the under Occupational safety

Section10 of the deceased as Section11 health

Occupational safety, per Section of the and working conditions

health and working 10 of the

Occupational Code,2020 along with

conditions Code, 2020. Occupation

safety

al safety,

, health and the details of affected

health and

working persons

working

conditions

conditions

Code,2020.

Code, 2020.

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

Sl. Accident/ Man-days lost Production Lost

No. Dangerous

Occurrence

B. 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

C. 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

D. Details of accident, dangerous occurrence and occupational

diseases:

(1) Details of accidents and dangerous occurrences:

Sl. Date of No. of No. of Number of Nature of Man-

No. accidents/ person persons persons injured occurrenc days

dangerous s killed received (Excluding e lost

occurrenc serious serious bodily

es bodily injury) and

injury thereby

prevented from

working for a

period of 48

hours or more

1.

(2) Details of Occupational diseases:

Sl. Notified Disease No.of cases

No

1

E. 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:

List of Principal Principal hazard Reasons for

Sl. Principal hazard not Mitigated till failure to

no. hazards Mitigation 31stDecember mitigate the

identified date same

1.

Sl. Designation Number of statutory Number of statutory

No. as per persons required persons employed

Code

Details of equipment/apparatus

Sl. Type of Numbers of

No. equipment/apparatus equipment/apparatus available

required

Particulars of emergency attended:

Sl. Nam Nature Response time Time taken Acti

No. e of of (time taken by for rescue & on

the emerge rescue services to recovery tak

mine ncy attend the en

emergency)

Additional Information:

Number of rescue rooms:

Number of rescue trained persons required:

Number of rescue trained person available:

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

Certified that the tables are duly filled in and information and figures given in

all the tables are correct to the best of my knowledge.

Signature of employer/occupier/Owner/Agent/Manager Place:

Dated:

PART III

Annual return period ending 31stDecember

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

Name of the principal employer:

Name of the establishment:

Registration number (LIN) of the establishment:

Details of the Contractors, wages paid, etc.:

Sl. Mo Na LIN Na Ma Amou Date Amount Date of Re

No nth me of me xi nt of of the payment mar

. and the oft m paid pay wages of wages ks

add con he u again men paid paid

res trac wo m st t of directly directly

s of tor rk nu wage wag to the to the

the m bill (if e bill contrac contract

con be applic t labour labour

trac r able)t (if by by

tors of o the appl Princip Principal

co contr icabl al Employe

ntr actor( e) Employ r (in case

act inclu er the

wo ding (in case contracto

rk EPF,E the r fails to

er SIC, contrac pay)

em Bonu tor fails

plo s etc.) to pay)

ye

d

Signature of the principal employer

Date:………