The Occupational Safety, Health and Working Conditions (Lakshadweep) Rules, 2025
Form 19
Official text
Open in the official PDF (pp. 240–243)
Tables and forms lose their layout when extracted; the PDF is the authoritative version.
(See rule 50)
Annual Return
For the Year ending 31st December,
1 Registration number of establishment:
2 Name of establishment:
3. Address of establishment:
4 Name of occupier. /Employer
5 Type of establishment:
A. Factory [ 2w(i)/2w(ii)/81]
B. Motor transport
C. Building or Other Construction Work
D. other
6. Nature of activity
7 NIC Code
8. hazardous process: yes or no
9 ownerships
(a) Public sector
(b) Private sector
(c) Joint sector
(d) Co-operative sector
(e) Proprietorship
(f) Partnership
(g) Government department/local authority
(h) L.L. P,
10. ls the establishment seasonal?
Particulars Male Female Total
Local Migrant Local Migrant Local Migrant
Adult
Adolescent
Total
11 No. of days worked in year.
12 (i) No. of Man-days worked during the year
(ii) Average number of employees and workers employed daily (man-days worked
divided by days worked)
Particulars Male Female Total
Local Migrant Local Migrant Local Migrant
Adult
Adolescent
Total
13. Total No. of man-hours worked including overtime but excluding the rest -interval
Particulars Male Female Total
Local Migrant Local Migrant Local Migrant
Adult
Adolescent
Total
14. Average number of employees and workers per week
15. In respect of establishments carrying on processes or operation declared dangerous
under furnish the following information.
Name of Average Number of persons
dangerous number of
process or persons
operation employed
carried on daily in each
of the process
of operation
given
Medically examined Declared unfit
Male Female Male Female
1 2 3 4 5 6
(i)
(ii)
(iii)
Etc
16. In respect of establishments carrying on processes or operation declared hazardous
under section, furnish the following information.
Name of Average Number of persons
dangerous number of
process or persons
operation employed
carried on daily in each
of the process
of operation
given
Medically examined Declared unfit
Male Female Male Female
1 2 3 4 5 6
(i)
(ii)
(iii)
Etc
Leaves With Wages
Particulars Total Number Number of Number of Number
Number of workers workers of
of workers granted dismissed/ workers
workers entitled leave died in respect
for leaves /discharged/ of whom
with left the wages in
wage services lieu of
leave
were paid
Adult Male
Female
Adolescent Male
Female
Safety Officer
Number of Safety Officer required Number of Safety officer appointed
Welfare Officer
Number of Welfare Officer required Number of Welfare officer appointed
Welfare Facilities
Shelter or Rest-Rooms or Lunch- Rooms
Canteen
Creches
Ambulance Room
Accidents
Type of Accident Number of Accident Man-days lost In Man-days lost
case employee or In case employee or
worker returned to worker returned to
duty during year in duty during
which accident succeeding year in
occurred which accident
occurred
Fatal
Non-fatal
Dangerous
occurrence
Total