FORM 26
Prescribed under Rule 121(3)

REPORT OF DANGEROUS OCCURRENCE WHICH DOES NOT RESULT IN DEATH ORBODILY INJURY

1.	Name and address of factory	:

2.	Name of occupier	:

3.	Name of manager	:

4.	Nature of industry	:

5.	Branch or department and exact place where the dangerous occurrence took place	:

6.	Date and hour of dangerous occurrence	:

7.	Nature of dangerous occurrence (State exactly what happened :

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

Signature of manager	:

Name, designation and address of manager	:

Date of despatch of report :

(To be completed by the Inspector of Factories)

District	:

Date of receipt	:

Number of the Causation	:

Dangerous occurrence	:

Date of investigation	:

Result of investigation	: