Form 17

{see sub-rule (a) of Rule 62}

Annual Return

Year ending 31st December, 20…

1. Licence number issued by the Chief Inspector-cum-Facilitator/Registering officer …………….

2. Name of the factory/ Establishment:-.........................................................................................

3. Name the occupier/Employer:-………………………………………………...........................

4. Name the manager......................................................................................since………………

5. District:-…………………………………………………........

6. Postal address, email-address and mobile no............................

7. Nature of Establishment/Industry (General/Hazardous/MAH).......................

8. Main work/product of the establishment…………………..

9. Details of employment:

(i) Average number of employees employed daily………….

(ii) Average number of workers [Section 2(1)(zzl)] employed daily…………

The average daily number should be calculated by dividing the aggregate of attendance on

working days by the number of working days in the year.[In reckoning attendances (1)

attendance of an employee for less than half of his scheduled working hours on a working day

shall be omitted,and attendance for half of his scheduled working hours or more on a working

day shall be treated as full attendance (2) attendance of both temporary as well as permanent

workers shall be counted. Attendances on separate shifts (e.g. night and days shifts) should be

counted separately. Days on which the factory was closed, for whatever cause, and days on

which the manufacturing processes were not carried should not be treated as working days.

Number of Number of “other

Employees Employees

Total apprentices apprentices”

directly by, directly by the

average

Employer contractor

Men

Women

Adolescent

Total

10. Name, address and email- address of the contractor (s).....................

11. Working hours:

(a) Normal hours worked per week for

Male Worker........................

Women Worker.....................

Other Apprentices.....................

(b) Total normal Man hour worked under Section 25……….

( Explanation; Man hour includes work done by employees)

12. Number of days worked in the year…..

13. What rest for intervals were given to employees (half an hour or one hour or two hour or others)

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

14. Whether first day of week was substituted as weekly holidays ? ………….Such numbers..................

15. Was the factory or part of factory is engaged in continuous process under schedule-II (details of class

of work)..............

16. Over time(Section 27):

Total Man hour worked during the period under Section 27………

17. Average number of women employees engaged in a shift or part thereof (Between 7 PM to 6 AM)

(a) Between 7 PM to 10 PM……….

(b) 10 PM to 6 AM…………

18. Compensatory Holidays

(1) Number of workers exempted from Section 26 of the code...........................

(2) Number of workers, who received holidays in the—

(a) Same month..................

(b) Following month..................

(c) Third month..........................

19. Leave with Wages(Section 32):

(a) Total number of persons employed during the year ………………............................

(b) Number of persons who are entitled to leave with wages during the year preceding the year for

which this return is submitted ………………

(c) Number of persons who are entitled to leave with wages during the year for which this return is

submitted …………………

(d)Number of persons who were granted leave during the preceding year………………………

(e)Number of persons who were granted leave during the year for which the return is submitted

……………………

(f)(i) The total number of workers discharged or dismissed from service during the year...............

(ii) Number of discharged workers paid wages in lieu of leave...............

(iii) Total amount of wages paid in lieu of leave............

(iv) Total number of workers who left the services of their own accord.. ..........................

(g) Number of persons who gave notice not to avail themselves of leave during the year in which

leave accrued ……………….

20. (i) Total number of days of involuntary unemployment during the year…………………

(ii) Number of unemployed workers...............

21. Does the factory come under—

(i)Section 2(1)(za)…………..

(ii) Section 82……………….

(iii) Section 80………………

22. Average daily number of employee employed in dangerous operations or Hazardous Process in a

factory or building and other construction work………………….................

23. (i) No. of safety officers employed under Section 22…………

(ii) Name of chief safety officer and email address………………..

(iii) Name of the secretary of safety committee ………………………….

24. If welfare officer is appointed under Section 24(2)(iv)………….

25. Is a canteen provided in compliance of Section 24(1)(v) and Rule made therein …………….

Does the canteen provide—

Cooked Cooke Refres Tea Approxima Are the Percentage of How is General

food d hment onl te charges expenditure the remarks

and food and tea y number of levied borne by the canteen

refreshmen only only workers below employer managed

t, patronizing cost price, if (details

etc. canteen so, state items regarding

(daily) provided items, if any,

below cost and amount

price subsidized

should be

given)

1 2 3 4 5 6 7 8 9

*(Point 25)-

1. If the columns are insufficient for giving details, a separate sheet may be

attached and detailed information submitted.

2. Enter "Nil" against the column which is not applicable to your factory.

26. CRECHE (For establishment ordinarily employing more than 50 workers)

Is a creche room provided/arranged in compliance of provisions of the Section 24(3) and rule made therein:

……………..

[Provide Details , a separate sheet may be attached ]

27. SHELTERS, REST ROOMS OR LUNCH ROOMS (For establishment ordinarily employing more than 50

workers)

Is a shelter, rest-room or lunch room provided in compliance of Section 24(2)(iii) and Rule made therein in

addition to a canteen? [Provide Details , a separate sheet may be attached ]

Details of

Average daily attendance Details of facilities

accommodation,

of workers of shelter, rest provided for General remarks

furniture and other

room or lunch room drinking water

equipments provided

1 2 3 4

28. ACCIDENTS

"Fatal and non-fatal accidents"

1 2 3 4

Total number of

accidents of dangerous

occurrences during the

year

dellik

snosrep

fo

rebmuN

derujni

snosrep

fo

rebmuN

Non-fatal accidents in which the workers returned to work

during the year

Occurring during the year Occurring during the previous

year

lataf

lataf

noN

tuohtiw

ecnerrucco

suoregnaD

yrujni

stnedicca

fo

rebmuN

derujni

snosrep

fo

rebmuN

no

tsol

syad

-nam

fo

rebmuN

ecnesba

fo

tnuocca

stnedicca

fo

rebmuN

derujni

snosrep

fo

rebmuN

no

tsol

syad

-nam

fo

rebmuN

ecnesba

fo

tnuocca

Total no. of fatal accidents in preceding year of this return period…………

I/We certify that information given by me/us is true and correct to the best of my/our knowledge.

The employer of every establishment shall furnish to Inspector-cum-Facilitator having jurisdiction on or before

31 January of each year an annual return in the form set forth for it.

Signature of Manager......................... Signature of Employer........................

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