FORM No. 21
Annual Return
Master form in respect of the Factories Act, 1948, Payment of Wages Act, 1936, Minimum Wages Act, 1948, Maternity Benefit Act, 1961, Workmen’s Compensation Act, 1923 and Industrial Employment (standing orders) act, 1946 as applicable to registered factories covered under the Factories Act, 1948.
For the year ending 31st December ……………………..
(A copy of this return should be sent to each of the prescribed authorities positively by 31st January of the succeeding year).
Part – A
Prescribed under Rule 127 (1) of the Factories Act, 1948
1. (a) Registration Number of factory :
(b) Licence Number of factory :
(c) Section of
the Act under : Section 2(m) (i)
which the factory is covered : Section 2(m) (ii)
Please tick (P)
the appropriate box : Section 85-chemical
Section
85-Non-chemical
2. Name of factory :
3. Name of occupier :
4. Name of manager :
5. Director :
6. Full postal
address of the factory
including Pin Code :
7. Industry
(a) (i) Nature
of Industry (Mention
what is actually manufactured,
including repairs of all types,
following the National
Industries Classification, 1988 at
the digit level)
(ii) NIC
Code Number (5 digit as
given in the Licence)
(b) Sector of
Industry : Public
Joint
Sector
Please tick (P)
the appropriate box Co-operative Sector
Private
Sector
(c) In case the
factory is a Major
Accident Hazard (MAH)
Installation furnish the following
information
( See Explanatory
Note ‘AA’)
Name of the MAH Substance
Quantity
( See Explanatory Note ‘BB’) in stock In
process
1.
2.
3.
8. (a) Number of days the factory
worked in the year
(See Explanatory Note ‘B’) :
(b) Number of weeks the factory
worked in the year :
Number of workers and particulars of employment
9. Number of mandays worked (i.e
aggregate number of attendance
during the year)
(See Explanatory Note ‘C’)
(a) Adults (i) Men :
(ii) Women :
(b) Adolescents (i) Male :
(ii) Female :
(c)
Children (i) Boys :
(ii)
Girls :
Total
10. Average number of
workers employed
daily i.e. Mandays worked divided by
Number of days worked (See Explanatory
Note ‘D’)
(a) Adults (i) Men :
(ii) Women :
(b) Adolescents (i) Male :
(ii) Female :
(c)
Children (i) Boys :
(ii)
Girls :
Total
11.
Total number of man-hours worked
including overtime but excluding rest
interval
(See Explanatory Note ‘E’)
(a) Adults (i) Men :
(ii) Women :
(b) Young persons (i) Male :
(ii) Female :
Total
12. Average number of hours worked per
week
i.e Total manhours worked ( Number of week the factory worked)
Average daily employment
(See Explanatory Note ‘F’)
(a) Adults (i) Men :
(ii) Women :
(b) Young persons (i) Male :
(ii) Female :
13. In respect of factory carrying on processes or operations declared dangerous under section 87, furnish the following information (See Explanatory Note ‘G’)
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Name of dangerous process or operation carried on (See Explanatory Note ‘G’) |
Average number of persons employed daily in each of the process or operation given on (See Explanatory Note ‘D’) |
Number of Person |
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Medically |
Declared |
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Male |
Female |
Male |
Female |
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(1) |
(2) |
(3) |
(4) |
(5) |
(6) |
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(i)
(ii) etc.
(iii)
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14. In respect of factories carrying on ‘hazardous process’ as defined in section 2 (cb) furnish the following information (See Explanatory Note ‘H’)
Name of the industry as per first schedule :
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Name of the hazardous process (See Explanatory Note ‘I’) |
Average number of persons employed daily in each of the process given in column I (See Explanatory Note ‘D’) |
Number of Person |
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Medically |
Declared |
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Male |
Female |
Male |
Female |
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(1) |
(2) |
(3) |
(4) |
(5) |
(6) |
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(i)
(ii) etc.
(iii)
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Leave with Wages
15. Total number of workers employed during the year
(See Explanatory Note ‘J’)
(a) Adults (i) Men :
(ii) Women :
(b) Young persons (i) Male :
(ii) Female :
Total
16. Number of workers who were entitled to
annual leave with wages during the year
(a) Adults (i) Men :
(ii) Women :
(b) Young persons (i) Male :
(ii) Female :
Total
17. Number of workers who were granted
‘Leave’ during the year
(See Explanatory Note ‘K’)
(a) Adults (i) Men :
(ii) Women :
(b) Young persons (i) Male :
(ii) Female :
Total
18. (a) Total number of workers
discharged/ :
dismissed from the service/quit employment
superannuated/died while in service during
the year.
(b) Number of workers in respect of whom
wages in lieu of leave were paid. :
SAFETY OFFICERS
(See Explanatory Note ‘L’)
19. (a) Is the factory notified for
appointment
of Safety Officers under Section 30-B(I) (i)
Yes No
(b) Is the factory notified for
appointment
of Safety Officers under section 40-B(ii)
[For Factories other than those in (a)
above] Yes No
(c) Number of Safety Officer appointed
Health and Safety Policy
Information to be furnished only by-
(a) Factories covered under section 2 (cb) or section 87 of the Act, and
(b) Factories other than (a) But employ ordinarily, in case of factories Registered under –
(i) Section 2(m) (i), 50 or
more workers, and
(ii) Section 2(m), 100 or more workers.
20. Has the factory formulated Health and
Safety Yes No
policy ? If Yes enclose a copy thereof
Safety Committee
[Information to be furnished only by (1) factories carrying on hazardous process or dangerous operations, and (ii) other factories employing 250 or more workers]
21. Is safety committee appointed
? Yes No
If more than one Committee give numbers
Emergency Plan
[Information to be furnished
factories covered under section 2(cb)
(See Explanatory Note ‘M’)
22. (a) Has the factory got on
site Yes No
emergency plan ?
Has it been revised
If so, when was it last revised?
Yes No
(b) If an off-site emergency
plan Yes No
is required to be prepared and
has it been prepared?
Medical facilities
23. Information to be furnished only be-
(a) Factories employing 200 or less
persons covered under
section 2(cb) or 87-
(i) Number of Factory Medical
Officers (appointed on :
retainer-ship basis or part-time basis)
(ii) Number of ambulance vans
available with the :
factory directly or through arrangement
(b) Factory employing above 200 workers covered under section 2(cb) or 87-
(i) Number of full time
Factory Medical Officers :
(ii) Number of ambulance vans available :
(c) All factories employing 500 or more workers :
(i) Number of full tome
Factory Medical Officers :
(ii) Number of ambulance vans :
(iii) Number of ambulance rooms provided :
Competent Supervisons
(See Explanatory Note ‘N’)
(Information to be furnished only be factories covered under section 2 (cb)
24. (a) Number of competent supervisors appointed :
(b) Number of competent supervisors who have received :
safety training as required under Model Rules 82-S
Industrial Hygienists
(See Explanatory Note ‘O’)
25. Number of industrial hygienists
employed to
monitor work environment as required under
Section 7-A Section 112
Canteen
26 (a) Is there a canteen provided in the
factory as Yes No
required under Section 46 (i.e. only those factories
will furnish information where in more than 250
workers are ordinarily employed)
(b) Is the canteen provided managed/run
(i) Departmentally,
or Yes No
(ii) Through contractor Yes
No
Shelters or Rest Rooms and Lunch Rooms
(Only those factories will furnish information wherein 150 or more workers are ordinarily employed)
27. As required under Section 47-
(a) Are there
adequate and suitable shelters or Yes No
rest rooms provided in the factory?
(b) Are there
adequate and suitable lunch rooms Yes No
provided in the factory (any canteen maintained in
compliance with section 46 will be accepted here also)
Creches
28. Is there a
crèches provided in the factory as required under Yes No
section 48 (i.e. only those factories will furnish information
wherein more than 30 women workers are ordinarily
employed)?
Welfare Officers
29. (a) Number of
Welfare Officers to be appointed as :
required under section 49 (i.e. only those factories
will furnish information wherein 500 or more workers
are ordinarily employed)?
(b) Number of
Welfare Officers :
actually appointed.
30. Accidents and
Dangerous Occurrences
[See Explanatory Note ‘P’ (I)]
(a) Total Number
Accidents involving
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Only non-fatal injuries [See Explanatory Note ‘P’ (2)] |
Fatal injuries as
well as non-fatal injuries |
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Number of |
Number of |
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Accidents |
Person injured |
Accidents |
Person injure |
Persons Killed |
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Categories |
Occurrences |
In- |
Out site the factory |
Occurrences |
In- |
Out site the factory |
In- |
Out site the factory |
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(1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
(8) |
(9) |
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1.Accidents 2. Dangerous occurrences not involving injuries/deaths 3. Dangerous occurrences involving injuries/deaths 4. Major accidents involving , injuries/death 5. Major accidents not involving injuries/death |
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* Explanatory Note ‘P’ (3)
(b) For injuries occurring inside the factory-
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Number of injuries occurring in |
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Hazardous Process under section 2 (cb) |
Dangerous operation under Section 87 |
Others |
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Number of |
Number of |
Number of |
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Accidents |
Persons |
Accidents |
Persons |
Accidents |
Persons |
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Fatal |
Non Fatal |
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Fatal |
Non Fatal |
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Fatal |
Non Fatal |
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(1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
(8) |
(9) |
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(c)
(i) Non-fatal injuries (Workers injured) :
during the year in which injured workers
returned to work during the same year
(aa) Number of injuries :
(bb) Mandays lost due to injures :
(ii) Non-fatal
injuries (workers injured)
occurring in the previous year in which
injured workers returned to work during
the year to which this return to work during
the year to which this return results.
(aa) Number of injuries :
(bb) Mandays
lost due to injuries (This should:
be the total mandays lost during the previous
year as well as in the current year)
(d) Non-fatal injuries (workers
injured) :
occurring in the year in which injured
workers did not return to work during the
year to which this return relates.
(aa) Number of injures :
(bb) Mandays lost due to injuries :
PART B
(Under the Payment of Wages Act, 1936)
32. (i) Number of Mandays worked (i.e. aggregate number of attendance) during the year for persons earning less than Rs. 1600 per month (See Explanatory Note ‘C’).
(a) Adults :
(b) Young Persons :
Total
(ii) Average number of workers employed daily (i.e mandays worked divided by number of day worked) for persons earning less than Rs. 1600 per month (See Explanatory Note ‘D’).
(a) Adults :
(b) Young Persons :
Total
13. Total wages paid including ‘Deduction’ under Section 7 (2) of the payment of Wages Act, 1936 for person getting less than Rs. 1600 per month of the following accounts.
(a) Basic wages
only :
(b) Dearness
allowance :
(c) Composite wages (i.e. if combined Basic wage and :
Dearness allowance paid)
(d) Overtime wages :
(e) Non-profit sharing Bonus :
(f) Any other bonus (other than profit sharing Bonus :
and on-profit sharing Bonus) forming part
of wages as defined under the Act
(g) Any other amount paid in cash which may
form part :
of wages as defined under the Act (Please specify)
(h) Arrears of pay in respect of previous year
paid :
during the year.
34. ‘Gross amount paid’ as remuneration to
person getting :
less than Rs. 1600 per month including deduction under
Section 7(2) of the Act on the following accounts.
(a) ‘Total wages paid’ (item 33) during the year : Rs.
(b) ‘Bonus paid’ during the
year :
(including arrears also, if paid during the year
This is statutory Bonus as well as Profits sharing Bonus)
(c) ‘Amount of Money Value of
Concession’ (See Explanatory:
Note ‘Q’) given during the year
PART C
(Under the Minimum Wages Act, 1948)
35. (i) Number of mandays worked (i.e. aggregate number of attendance during the year by the persons covered the Minimum Wages Act, 1948 (See Explanatory Note ‘C’)
(a) Adults :
(b) Young Persons :
Total
(ii) Average number of persons employed (covered under the Minimum Wages Act, 1948) daily (i.e. mandays worked divided by number of days worked) during the year (See Explanatory Note ‘D’)
(a) Adults :
(b) Young Persons :
Total
36. ‘Total Wages Paid’ to workers covered under the Minimum Wages Act, 1948.
(i) Wages paid
in cash (a) Basic wages only : Rs.
(b)
Dearness Allowance : Rs.
(c)
Composite wage if paid : Rs.
(ii) Cash value of wages paid in
kind (See Explanatory Note ‘R’)
(iii) Overtime wage : Rs.
(iv) Any
other amount paid in cash
(Please specify) : Rs.
Total : Rs.
PART.D
(Under the Meternity Benefit Act, 1961/the ESIC Act, 1948)
37. Aggregate number of women permanently
:
or temporarily employed during the year
(a particular worker is to be counted once
only )
38. Number of women
who claimed maternity :
benefit during the year.
39. Number of meternity benefit claims
:
accepted and paid either fully or partially.
(a) Total :
(b) From current year’s claim
40 (a) Number of maternity benefit in
which :
medical Bonus was paid.
(b) Amount of medical Bonus paid :
41. Amount of maternity benefit paid
including :
medical bonus.
42. Number of cases in which women
enjoyed :
full maternity leave prior to confinement.
PART E
(Under the Workman’s Compensation Act, 1923/ESIG Act, 1948)
43. Average number of workers (covered
under
the Act) employed daily i.e. mandays
worked divided by number of days
worked (See Explanatory Note ‘S’ & ‘D’)
(a) Adults :
(b) Young Persons :
Total
44. Injuries Compensated (Occupation – wise)
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Name of |
Number of injuries (See
Explanatory Note ‘T’) in respect of which final compensation has been
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Amount of compensation (See Explanatory Note ‘U’) Paid Rs. |
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Death |
Permanent |
Temporary Disablement |
Death |
Permanent |
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