Serial Number

Date & time of notice

Name & Sl.No. of the persons involved in the register of adult/child register

ESIC insurance number

Date

Time

Place

Cause of accident/major accident/dangerous occurrence

Nature of injuy/dangerous occurrence

What exactly was the injured person if any, doing at that time

Name of the person giving the notice

Name, address and occupation of two witness

Date of return of injured person to work

Number of days the injured person was absent from the work including holidays and off-days

Signature and designation of the person who makes the entry with date

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

(13)

(14)

(15)