FORM No. 18

(Prescribed under Rule 123)

 Report of accident including dangerous  occurrence resulting in death or  bodily injury

ESIG Employer’s Code No. ………   Registration No. …………………….

Name & Address of Local ESIG        Licence Number ……………………

Office ………………………………

NIG Code Number …………………

(As given in the licence)

1.  Name and address of factory                 :

2.  Name, address and telephone number
     of the occupier                                     :

3.  Nature of Industry (As given in the
     licence)                                                 :

4.  Date, shift and hour of accident or
     dangerous occurrence                           :

5.  Department/Section and exact place
     where the accident or dangerous
     occurrence took place                           :

6.  (a) Describe briefly how the accident       
     or dangerous occurrence took place:

     (b) Did it involve ExplosionFire   :

     Emission of toxic substance (s) emitted

7.  Give the total number of persons
     injured/killed                                         :

 8.  Name and address of witnesses      1.

                                                          2.

9.  Cause of accident of dangerous
     occurrence

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

Signature of Manager/Occupier

Date :                                               Name (in block letters)                                            

Notes :    1.  If in any accident/dangerous occurrence, persons outside the factory premises are injured or killed, please furnish the information to the extent available.

2.  Details regarding injury and persons injured/killed should be supplied in the format given in the annexure.

Address & Telephone Number ………………………

( To be completed by the Inspector of Factories)

1.  Date of receipt of the report                     :

2.  District                                                    :

3.  Number allotted accident involving
     injury and / or fatality                               :

4.  Date of investigation                                :

5.  (a) Number allotted to dangerous
     occurrence involving reportable
     injury and / or fatality                               :

6.  Classification of accident                         :

7.  (a) Clause – wise (Give code)                  :

     (b) Industry-wise ( Give NIG Code)         :

     (c) Dangerous operation-wise (Give
          schedule number under section 87)      :

     (d) Hazardous process-wise-Section
          2(cb)                                                  :

     (e) Occupation-wise                                :

          (NIG-Code Number)                          :

8.  Result of investigation                             :

9.  Remarks, if any                                       :

Date : Signature of Inspector

 

Name ( In block letters)

Annexure
Particulars of persons inured/killed

 1.  Particulars of injured/killed person

     (a) Name                                       :

     (b) Age                                          :

     (c) Sex                                          :

     (d) Serial Number in the register of
          adult workers                            :

     (e) Address                                   :

     (f) Precise occupation                    :

     (g) Nature of job                            :

2.  Cause of Injury Explosion Fire

     Emission of Toxic Substance Others           

     (Please specify)

3.  Particulars  of injury                      

     (a) Fatal (Time and date of death)

     (b) Non-fatal (If serious, give the extent    :
of injury such as loss of limb/sight
and hearing, fracture, permanent
impairment, severe burns.)        

     (c) State whether the injured person :
was disabled for more than 48 hours

     (d) Location of injury (i.e. part of body     :
such as right leg, left hand, left eye,
etc. injured.                              

4.  (a) State exactly what the injured person   :
          was doing at the time  of accidents or
          dangerous occurrence.

     (b) Does this work fall in the category            Hazardous process
          of hazardous/ dangerous process or         Dangerous process
          operations (Please tick mark) (P)             operation
          in the box.

5.  (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
          accident or dangerous occurrence

6.  In case the accident or dangerous   :
occurrence took place while traveling in
the employer’s transport, state whether

     (a) the injured person was traveling as a    :
     passenger to and from his place of
     work

     (b) the injured persons was traveling         :
     with the express or implied
     permission  of his employer

     (c) the transport is being operated by or   :
     on behalf of the employer or some
     other persons by whom it is provided
     in pursuance of arrangements made
     with the employer.

     (d) the vehicle is being operated in the       :
     ordinary course of public transport
     service.

7.  In case the accident took place while        :
meeting emergencies, state.

     (a) its nature : and                          :

     (b) whether the injured person at the         :
     time of accident was employed for
     the purpose of his employer’s trade
     or business in or about the premises
     at which the accident took place

8.  (a) Physician, dispensary, or hospital        :

          from whom or in which injured person
     received or is receiving treatment

     (b) Name of dispensary/panel doctor        :
     elected by the injured person