Form XXI

[(See Rule 27(1)(a)]

REGISTER OF WOMEN EMPLOYEES

Name of Establishment

1. Serial Number.

2. Name of woman and her father’s (or, if married, husband’s) name.

3. Date of appointment.

4. Nature of work.

5. Dates with month and year in which she is employed, laid off and not employed.

No. of days No. of days laid No. of days not

Month Remark

employed off employed

a b C D e

6. Date on which the woman gives notice under section 62.

7. Date of discharge/dismissal, if any.

8. Date of production of proof of pregnancy under section 62.

9. Date of birth of the child.

10. Date of production of proof of delivery/miscarriage/Medical Termination of pregnancy/ tubectomy

operation/death/adoption of the child.

11. Date of production of proof of illness referred to in section 65.

12. Date with the amount of maternity benefit paid in advance of expected delivery.

13. Date with the amount of subsequent payment of maternity benefit.

14. Date with the amount of bonus, if paid, under section 64.

15. Date with the amount of wages paid on account of leave under sections 65(1) & 65(3).

16. Date with the amount of wages paid on account of leave under section 65(2) and period of leave granted.

17. Name of the person nominated by the woman under section 62.

18. If the woman dies, the date of her death, the name of the person to whom maternity benefits and/or

other amount was paid, the amount thereof, and the date of payment.

19. If the woman dies and the child survives, the name of the person to whom the amount of maternity

benefit was paid on behalf of the child and the period for which it was paid.

20. Signature of the employer of the establishment authenticating the entries in the register of women

employees.

21. Remarks column for the use of the Inspector-cum-Facilitator.