Form 10

{ See sub-rule (1), sub-rule (2) of rule 15}

Notice of Accidents, or dangerous occurrence resulting in Death or Bodily Injury or disability

Dated............................

To,

................................................

....................................................

Sir,

I hereby give notice under Section 10 of the Occupational Safety, Health and Working Conditions

Code 2020 that fatal/non-fatal accident occurred in this establishment to the person mentioned below:

1. Name of occupier/Employer.....................................

2. Address of E.S.I. Employer's Code No...............................................premises where accident

or dangerous occurrence took place....................

3. Nature of Industry........................................................

4. Branch or department and exact place where the accident or dangerous occurrence took

place.................

5. Name and address of injured person.......................................

(a) Sex..................................................................

(b) Age (last birthday)....................................................

(c) Occupation of the injured person.......................................

6. Local E.S.I. Office to which the injured person is attached.....................

7. Date, shift and hour of accident or dangerous occurrence.......................

(a) Hour at which the injured person started work on the day of accident or dangerous

occurrence..............................................................

(b) Whether wages in full or part are payable to him for the day of the accident or dangerous

occurrence..............................................................

8. Cause or nature of accident or dangerous occurrence..........................

9. Cause of accident or dangerous occurrence:

(a) If caused by machinery................................................

(i) Give the name of the machine and the part causing the accident or dangerous

occurrence........................................................

(ii) State whether it was moved by mechanical power at that time..........

(b) State exactly what the injured person was doing at that time................

(c) In your opinion, was the injured person at the time of accident or dangerous

occurrence...........................................................

(i) Causing contravention of provisions of any law applicable to him, or

(ii) causing contravention of any orders given by or on behalf of his employer, or

(iii) causing without instructions from his employer.

(d) In case reply to (c), (i)(ii) or (iii) is in the affirmative whether the act was done for the

purpose of securing safety in connection with the employer's trade or business.

(e) In case the accident or dangerous occurrence happened while travelling in the employer's

transport state whether...................................................

(i) the injured person was travelling as a passenger to or from his place of

work.....

(ii) the injured person was travelling with the express or implied permission of

his employer,

(iii) the transport is being operated by or on behalf of the employer or some

other person by whom it is provided in pursuance of arrangements made

with the employer, and

(iv) the vehicle is not/being operated in the ordinary course of public transport

service.

(f) In case the accident or dangerous occurrence happened while meeting the emergency

state.............................................................................

(i) its nature................................................................

(ii) whether the injured person at the time of accident or dangerous occurrence

was employed for the purpose of his employer's trade or business in or

about the premises at which the accident or dangerous occurrence took

place.

(g) Describe briefly how the accident or dangerous occurrence occurred.

(h) Name and addresses of witnesses : (1) ……………… (2) ……………

(i) (a) Nature and extent of injury (e.g. fatal, loss of finger, fracture of leg, sealed or scratch

and followed by sepsis.)

(b) Location of injury (right leg, left hand or left eye etc.)

(j) (a) If the accident or dangerous occurrence is not fatal, state whether the injured person

was disabled for more than 48 hours.

(b) Date and hour of return to work.

(k) (a) Physician, dispensary or hospital from whom or in which the injured person received

or is receiving treatment.

(b) Name of dispensary/panel doctor selected by the injured person.................

(i) Has the injured person died............................................

(ii) If so, date of death........................................................

I certify that to the best of my knowledge and belief, the above particulars are correct in every

respect.

Signature

Name and Designation of the

Occupier or Manager-Employer

Employer's Address and Code No

(This space is to be completed by the Inspector-cum-Facilitator)

Date of receipt.

Number of accidents or dangerous occurrences. Causation number, other particulars (e.g. fatal leg

injury, arm injury, etc.)

Date of Investigation...............................................................

Result of Investigation............................................................