Form 37

[See rule 105]

Monthly Return

Return for the month ending on …………………………………………………

Name of the factory …………………………………………………………………..

Address of the factory ……………………………………………………………….

License Number …………………………………………………………………………

Name of the hazardous process/dangerous operation undertaken

……………………………………………………

Number Number Date of Name Number Number Number Details of

of of examinat and of of of alternativ

Workers/e Workers/e ion of the addre workers workers/e workers/e e work

mployees mployees worker/e ss of /employ mployees mployees given to

normally employed mployees the ee declare fit declared Workers/e

employed in the engaged exami examine unfit with mployees

during the hazardous in the ning d details who have

month manufact dangerou medic declared

uring s al unfit

process operation office

r

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