FORM 29
Prescribed under Rule 125
ANNUAL RETURN

For the year ending 31st December, 20..........

1.	Registration number of factory	:

2.	Name of factory	:

3.	Name of occupier	:

4.	Name of the manager	:

5.	District	:

6.	Full postal address of factory	:

7.	Nature of industry	:

Number of workers and particulars of employment

8.	No. of days worked in the year	:

9.	No. of man-days worked during the year

(a) Men	:

(b) Women	:

(c) Children	:

10.	Average number of workers employed daily

(a) Adults
(i) Men	:
(ii) Women	:

(b) Adolescents
(i) Male	:
(ii) Female	:

(c) Children
(i) Male	:
(ii) Female	:

11. Total no. of man-hours worked including overtime.

(a) Men :

(b) Women	:

(c) Children	:

12.Average number of hours worked per week (See explanatory note)

(a) Men	:

(b) Women	:

(c) Children :

13. (a) Does the factory carry out any process or operations declared as dangerous under Section 87 (See Rule 116):
(b) If so, give the following information

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Name of the dangerous process Average no. of persons employed daily in each
Or operations carried on of the processes or operations given in Col.1

1 2

-----------------------------------------------------------------------------------------------------------------i)

ii)

iii) etc.

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Leave with Wages

14.	Total number of workers employed during the Year :
(a) Men	:
(b) Women	:
(c) Children	:

15. Number of workers who were entitled to annual leave wit wages during the year

(a) Men	:
(b) Women	:
(c) Children	:

16. Number of workers who were granted leave during the year

(a) Men	:
(b) Women	:
(c) Children	:

17. (a) Number of workers who were discharged, or dismissed from the service, or quit employment, or were superannuated, or died while in service during the year :

(b)	Number of such workers in respect of when wages in lieu of leave were paid :

18. (a) Number of Safety Officers required	to be appointed as per notification under Section 40-B :

(b)	Number of Safety Officers appointed :

Ambulance room
19. Is there an ambulance room provided in the factory as required under Section 45 ? :

Canteen

20. (a) Is there a canteen provided the factory as required under Section 46? :

(b) Is the canteen provided managed

i) departmentally, or	:
Ii) through a contractor?	:

Shelters or Rest Rooms and Lunch Rooms

21.	(a) Are there adequate and suitable shelters or rest rooms provided in the factory as required under Section 47? :

(b) Are there adequate and suitable lunch rooms provided in the factory as required under Section 47?	:

Creches

22. Is there a Creche provided in the factory as required under Section 48 ?	:
23. (a) Number of Welfare Officers to be appointed as required under Section 49 :
(b) Number of Welfare Officers appointed :

Accidents

24.(a) Total number of accidents

i) Fatal	:
ii) Non-Fatal :

(b) Accidents in which workers returned to work during the year to which this return relates	:

i) Accidents (workers injured) occurring during the year in which injured workers returned to work during the same year

(aa) Number of accidents	:
(bb) Man-days lost due to accidents	:

ii) Accidents (workers injured) occurring in the previous year in which injured workers returned to work during the year to which this return relates

(aa) Number of accidents	:
(bb) Man-days lost due to accidents	:

(c) Accidents (workers injured) occurring during the year in which injured workers did not return to work during the year to which this return relates

i) Number of accidents	:
ii) Man-days lost due to accidents	:

Certified that the information furnished above is to the best of my knowledge and belief, correct.

Signature of the manager :

Date: