Form IX

[See Rule-21 (3)]

UNIFIED ANNUAL RETURN FORM

FOR THE YEAR ENDING DECEMBER………………...20……….

Single 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

Instructions to fill up the Annual Return

(1) This return is to be filled-up and furnished on or before 28th or 29th February every year.

(2) The return has two 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 in addition to Part-I.

(4) The terms Establishment and Mines shall have the same meaning as under the Occupational

Safety, Health and Working Conditions Code, 2020.

(5) This return is to be filed in case of contractor or manpower supplier who have engaged more

than 50 workers and in case of Mines even if there is one worker employed in the relevant

period.

Applicable to All Establishments - Part-I

A. General Information:

Sl.

Instructions for filling the column

No.

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

Period should be calendar year

2. Period of the Return From -To-

3. Name of the Establishment

4. Email ID

5. Telephone No.

6. Mobile number

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

C. Details of Manpower Deployed

Details Directly employed Employed through Contractor

yrogetaC

llikS

dellikS

ylhgiH dellikS

dellikS-imeS

dellikS-nU

dellikS

ylhgiH dellikS

dellikS-imeS

dellikS-nU

dnarG

latoT

Directly employed Employed through Contractor

latoT

dnarG

(i) Maximum No. of

employees

employed in the

establishment in

any day during the

year

elaM

elameF

rednegsnarT

latoT elaM

elameF

rednegsnarT

latoT

(ii) Average No. of

employees

employed in the

establishment

during the year

elaM

elameF

rednegsnarT

latoT elaM

elameF

rednegsnarT

latoT

(iii) Migrant Worker out

of (ii) above

elaM

elameF

rednegsnarT

latoT elaM

elameF

rednegsnarT

latoT

(iv) Number of fixed

term employee

engaged

elaM

elameF

rednegsnarT

latoT elaM

elameF

rednegsnarT

latoT

D. Details of contractors engaged in the Establishment:

Sl.

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

No.

E. Details of various Health and Welfare Amenities provided.

Sl. Statutory (specify the

Nature of various welfare amenities provided Instructions for filing

No. statute)

Applicable to all establishments

Whether facility of Canteen provided (as per Tick yes or no in the where in hundred or more worker

1.

section 24 (i) (v) of OSH Code, 2020) box including contract labour are

ordinarily employed

Crèches (as per section 67 of Code on Social Applicable to all establishments

Tick yes or no in the

2. Security Code, 2020 and Section 24 (3) of the where fifty or more workers are

box

OSH Code 2020) employed

Applicable to mines, building and

Ambulance Room (as per section 24(2)(i) of Tick yes or no in the other construction work wherein

3.

OSH Code, 2020) box more than five hundred workers are

ordinarily employed

In case of mine 100 or more workers

Safety Committee (as per Section 22(1) of OSH Tick yes or no in the

4. and in case of BOCW 250 or more

Code, 2020. box

workers are ordinarily employed.

Applicable to establishments and

factories employing 500 workers or

Safety Officer (as per section 22(2) of OSH No. of safety officers more, factory carrying on hazardous

5.

Code, 2020) appointed process and BOCW employing 250

workers or more, and mines

employing 100 or more workers.

There is no specification for

minimum number of Qualified

No. of Qualified

Qualified Medical Practitioner (as per Section Medical Practitioners to be engaged

6. Medical Practitioners

12 (2) of OSH Code 2020. / consulted in establishment.

engaged/ consulted.

However, this detail is required to

have a data on occupational health.

F. The Industrial Relations: Instructions for filing

Industrial

Has the Works Committee been functioning. (section 3 of establishment in which

1. Yes/No

IR Code, 2020) 100 or more workers

are employed

(a) Date of its constitution.

Industrial

Whether the Grievance Redressal Committee constituted establishment

2. Yes/No

(section 4 of IR Code, 2020) employing 20 or more

workers.

3. Number of Unions in the establishments.

Whether any negotiation union exist (Section 14 of IR

4. Yes/No

Code, 2020)

Whether any negotiating council is constituted (Section 14

5. Yes/No

of IR Code, 2020)

Number of workers discharged, dismissed, retrenched or whose services were

6.

terminated during the year:

Discharged Dismissed Terminated or Grand

Retrenched

Removed Total

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

Sl. Period / No. of man- Loss in term of

Reasons

No. Date days lost money

(a) Strike

(b) Lockout

8. Details of retrenchment / lay off

No. of persons Details of No. of

Sl. retrenched payment paid to workers laid off No. of man-days

No. During the retrenched during lost due to lay-off

period employees the period

G. Details pertaining to maternity benefit:

Amount of

No. of female No. of female deduction, if any

No. of female

employees who employees paid made from the

employees

availed maternity leave medical bonus wages of female

employees

H. Details of payment of bonus:

Sl. No. of employees covered

Dates on which the Bonus paid Total amount of bonus actually paid

No. under the Bonus provision

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

Total number of cases

Total number of accidents Total number of

of Notifiable Diseases

by which a person injured is Total number of fatal Dangerous

specified in Third

Sl. prevented from working for accidents and names of the Occurrences as