FORM No. 18 A

(Prescribed under Rule 123 (4)

 Report of dangerous occurrence which does  not result in bodily injury

Registration No……………………..

Licence No. ……………………….

NIC Code No ………………………..             (as given in the licence)

1.  Name and Address of the factory   :

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

3.  Name of the Manager                     :

4.  Name of Industry                           :

5.  Department/section and exact place          :
where the dangerous occurrence
took place

6.  Date and hour of dangerous occurrence   :

7.  (a) Type of dangerous occurrence  :
     (See over leaf)

     (b) Did it involve Explosion Fire     Emission of flammable
                                                                             Explosure
                                                                             substance (s)

8.  State exactly what happened                                   Substance(s) emitted

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

     Signature of Manager

     Name (block letters)

     Address & Tel. No.

( To be completed by the Inspector of Factories)

1.  Date of receipt of the report                     :

2.  District                                                    :

3.  (a) Number allotted to the dangerous        :
occurrence not involving injuries and/
or death.

     (b) Number allotted to ‘Major accident’    :
not involving reportable injuries
and/or death.

4.  Date of investigation.                               :

5.  Cause                                                     :

6.  NIC-Code (As given in the licence) :

7.  Result of investigation                             :

Schedule

 The following classes of dangerous occurrence, whether or not they are     attended by personal injury or disablement-

 1.  Bursting of a plant used for containing or supplying steam under pressure greater than atmospheric pressure.

2.  Collapse or failure of a crane, iderrick, which, hoist or other appliance in raising or lowering persons or goods, or any part thereof, or the overturning of a crane.

3.  Explosion, fire, bursting out, leakage or escape of any molten metal or hot liquor or gas causing bodily injury to any person or damage to any room or place in which persons are employed, or fire in rooms of cotton pressing factories when a cotton opener is in use.

4.  Explosion of a receiver of container used for the shortage at a pressure greater than atmospheric pressure of any, gas or arises ( including air) or any liquid or solid resulting, from the compressor of gas.

5.  Collapse or subsidence of any floor, gallery, roof, bridge, tunnel, chimney wall, bunding or any other structure.