The Rajasthan Occupational Safety, Health and Working Conditions Rules, 2026
Form 19
Official text
Open in the official PDF (pp. 190–191)
Tables and forms lose their layout when extracted; the PDF is the authoritative version.
(see rule 49(1)(d) & 53)
Register of leave with Wages
Registration No. of factory or establishment……
Name of factory or establishment:
Part I - Adults
Part II - Adolescents
Name of worker :
Father’s Name:
Department :
Sl. Sl.no. in Date of Interruptions
the entry
N register into Sickness Authorize Lock Out or Involuntary Others
o of service and d Leave unemployment
worker accident Legal Strike
s s
1 2 3 4 5 6 7 8
Leave Whether Date from Wages for Discharged Remarks
due with leave not which the worker
desired worker is Leave
effect from during the allowed Paid in Date of Date &
amount of
next 12 leave
Discharge payment
months
made in
lieu of
leave due
9 10 11 12 13 14 15
Note: - Separate page shall be allotted to each worker
633