Form 22

(see rule 49(5), rule 51 & 75(8))

UNIFIED ANNUAL RETURN FORM

FOR THE YEAR ENDING……..

Single Annual 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 and the rules made there under.

Instructions to fill up the Annual Return

(1) This return is to be filled-up and furnished on or before 1st 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. Instructions for filling the column

No.

1. Labour EPFO, ESIC, MCA, MoLE (LIN)

Identification

Number

2. Period of the From - To- Period should be calendar year

Return

3. Name of the

Establishment

4. Email ID

5. Telephone No.

6. Mobile number

7. Premise name

8. Sub-locality

9. District

‍635

10. State

11. Pin code

12. Geo Co-

ordinates

B(a). Hours of

Work in a

day

B(b). Number of

Shifts

C. Details of Manpower Deployed

Details Directly employed Employed through Contractor Grand

Total

Skill Highly Skill Semi- Un- Highly Skille Semi- Un-

Category Skille ed Skilled d

Skilled Skille Skilled Skille

d

d d

(i) Maximum M/F/ M/F M/F/T M/F/ M/F/T M/F/ M/F/T M/F/

No. of T /T T T T

employees

employed in

the

establishment

in any day

during the

year

(ii) Average No. to M/F M/F/T M/F/ M/F/T M/F/ M/F/T M/F/

No. of be /T T T T

employees indicat

employed in

ed

the

establishment

during the

year

(iii) Migrant M/F/T M/F M/F/T M/F/ M/F/T M/F/ M/F/T M/F/

Worker out of /T T T T

(ii) above

(iv)Number of M/F/T M/F M/F/T M/F/

fixed term

employee /T T

engaged

D. Details of contractors engaged in the Establishment:

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

No. Contractor

E. Details of various Health and Welfare Amenities provided.

Sl. Nature of various welfare Statutory (specify Instructions for filling

amenities provided the statute)

No

.

1. Whether facility of Tick yes or no in Applicable to all establishments where in

Canteen provided (as per the box hundred or more worker including contract

section 24(v) of OSH Code, labour were ordinarily employed

2020)

2. Crèches (as per section 67 Tick yes or no in Applicable to all establishments where fifty or

of Code on Social Security the box more workers are employed

Code, 2020 and Section

24 of the OSH Code 2020)

3. Ambulance Room (as per Tick yes or no in Applicable to mine, building and other

section 24(2)(i) of OSH the box construction work wherein more than five

Code, 2020) hundred workers are ordinarily employed

4. Safety Committee (as per Tick yes or no in Applicable to establishments and factories

Section 22(1) of OSH Code, the box employing 500 workers or more, factory

2020. carrying on hazardous process and BoCW

employing 250 workers or more, and mines

employing 100 or more workers.

5. Safety Officer (as per No. of safety In case of mine 100 or more workers and in

section 22(2) of OSH Code, officers appointed case of BoCW 250 or more workers are

2020) ordinarily employed.

6. Qualified Medical No. of Qualified There is no specification for minimum number

Practitioner (as per Medical of Qualified Medical Practitioner employed in

Section 12 (2) of OSH Code Practitioner establishment. However, this detail is required

2020. appointed. to have data on occupational health.

‍637

F. The Industrial Relations: Instructions for filling

1. Is the Works Committee has been functioning. Yes/No Industrial

(section 3 of IR Code, 2020) establishment in which

100 or more workers

are employed

(a) Date of its constitution.

2. Whether the Grievance Redressal Committee Yes/No Industrial

constituted (section 4 of IR Code, 2020) establishment

employing 20 or more

workers are employed

3. Number of Unions in the establishments.

4. Whether any negotiation union exist (Section 14 Yes/No

of IR Code, 2020)

5. Whether any negotiating council is constituted Yes/No

(Section 14 of IR Code, 2020)

6. Number of workers discharged, dismissed, retrenched or whose services

were terminated during the year:

Discharged Dismissed Retrenched Terminated or Gran

Removed d

Total

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

Sl. Reasons Period No. of Loss in term

/ Date mandays of money

No.

lost

(a) Strike

(b) Lockout

8. Details of retrenchment / lay off

Sl. No. of Details of No. of No. of man-days lost due to

persons payment workers lay-off

No. retrenched

paid to laid off

during the retrenched during

period employees the period

G. Details pertaining to maternity benefit:

No. of female No. of female No. of female No. of deduction of wages, if

employees employees availed employees paid any made from female

maternity leave medical bonus employees

H. Details of payment of bonus:

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

covered under the Bonus

actually paid

No.

provision

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

Sl. Total number of Total number of fatal Total number of Total number of

accidents by which a accidents and names of cases of Notifiable

No. Dangerous Diseases specified

person injured is the deceased as per

Occurrences as in Third

prevented from working Section 10 of the OSH

defined under

for a period of 48 hours Code, 2020. Schedule of the

or more as per Section Section 11 of the OSH OSH

10 of the OSH Code,

Code, 2020 Code, 2020 along

2020.

with the details of

affected

persons

J. Mandays and Production Lost due to accidents / dangerous occurrence

Sl. Accident/Dangerous Mandays lost Production Lost

Occurrence

No

.

‍639

PART II

(see rule 75)

ANNUAL RETURN

Period ending 31st December……….

(to be submitted by the principal employer on Shram Suvidha Portal/Official Portal)

1. Name of the principal employer:

2. Name of the establishment:

3. Registration number (LIN) of the establishment:

4. Details of the Contractors, wages paid, etc.:

Sl. Month Name and LIN of the Name of Maximum Amount Date of Amount of Date of Remarks

address of contractor the work number of paid payment the wages payment

the contract against of wage paid of wages

contractors worker wage bill bill directly to paid

employed (if (if the directly to

applicable) applicable) contract the

to the labour by contract

contractor Principal labour by

(including Employer Principal

EPF, ESIC, (in case Employer

Bonus etc.) the (in case

contractor the

fails to contractor

pay) fails to

pay)

Date: Signature of the

principal employer