Form XIX

(See rule-34)

ANNUAL RETURN

UNIFIED ANNUAL RETURN FORM FOR THE YEAR ENDING………………..

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 filled-up 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. No. Instructions for filling the column

Labour Identification EPFO, ESIC, MCA, MoLE (LIN)

Period of the Return From – To- Period should be calendar year

Name of Establishment

EmailId

Telephone No.

Mobile No.

Premise name

Sub- locality

District

State

Pin

Geo Co-ordinates

B(a) Hours of Work in a day

B(b) Number of Shifts

A. Details of Manpower Deployed.

Details Directly employed Employed through Contractor

Maximum No. of employees employed in the

Male Female Transgender Total Male Female Transgender Total

establishment in any day during the year

Average No. of employees employed in the

Male Female Transgender Total Male Female Transgender Total

establishment during the year

Migrant Worker out of above Male Female Transgender Total Male Female Transgender Total

Number of fixed term employee engaged Male Female Transgender Total Male Female Transgender Total

D. Details of contractors engaged in the Establishment:

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

B. Details of various Health and Welfare Amenities provided.

Nature of various welfare Statutory

Sl. No Instructions for filling

amenities provided (specify the statute)

Whether facility of Canteen Applicable to all establishments where in

Tick yes or no

1 provided (as per section 24 (v) hundred or more worker including contract

in the Box

of OSH Code, 2020) labour were ordinarily employed

Creche (as per section 67 of

Code on Social Security Code, Tick yes or no Applicable to all establishments where fifty or

2

2020 and Section 24 of the in the Box more workers are employed

OSH Code 2020)

Ambulance Room (as per Applicable to mine, building and other

Tick yes or no in

3 section 24(2)(i) of OSH Code, construction work wherein more than five

the Box

2020) hundred workers are ordinarily employed

Applicable to establishments and factories

Safety Committee (as per employing 500 workers or more, factory

Tick yes or no in

4 Section 22(1) of OSH Code, carrying on hazardous process and BOCW

the Box

2020 employing 250 workers or more, and mines

employing 100 or more workers

In case of mine 100 or more workers and

Safety Officer (as per section No. of safety offi-

5 in case of BOCW 250 or more workers are

22(2) of OSH Code, 2020) cers Appointed

ordinarily employed.

There is no specification for minimum

Qualified Medical Practitioner No. of Qualified number of Qualified Medical Practitioner

6 (as per Section 12 (2) of OSH Medical Practi- employed in establishment. However, this

Code 2020. tioner appointed detail is required to have data on

occupational health.

C. The Industrial Relations:

Is the Works Committee has been functioning. (section 3 of IR Code, 2020)

1 Yes/No

(a) Date of its constitution

2 Whether the Grievance Redressal Committee constituted (section 4 of IR Code, 2020) Yes/No

3 Number of Unions in the establishments Yes/No

4 Whether any negotiation union exist (Section 14 of IR Code, 2020) Yes/No

5 Whether any negotiating council is constituted (Section 14 of IR Code, 2020) Yes/No

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

6 Yes/No

nated during the year:

Discharged Dismissed Retrenched Terminated or Removed Grand Total

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

Sl. No. Reasons Period/Date No. of man days lost Loss in term of money

(a) Strike

(b) Lockout

8. Details of retrenchment /lay off

Sl. No. of persons Details of payment paid No. of workers laid No. of man-days

No. retrenched during to retrenched employees off during the period lost due to lay-off

the period

D. Details pertaining to maternity benefit:

No. of female No. of female employees No. of female employees No. of deduction of wages,

employees availed maternity leave paid medical bonus if any made from female

employees

E. Details of payment of bonus:

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

No. Bonus provision. actually paid paid

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

Sl. Total number of accidents by which a Total number of fatal Total number of

No. person injured is prevented from accidents and names Dangerous Occurrences as

working for a period of 48 hours or of the deceased as per defined under Section 11

more as per Section 10 of the OSH Section 10 of the OSH of the OSH Code, 2020

Code, 2020. Code, 2020.

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

Sl. Accident/Dangerous Occurrence. Man days lost Production Lost

No.