FORM 27 (Annual Return)

[see rule 119 (1)]

For the year ending 31st December, 2012

GENERAL INFORMATION
1

Name and address of FactoryStreet, City, Taluka, District.

Name and Designation of Occupier

Name and Designation of Manager

Contact Details of Occupier

Contact Details of Manager

Registration No. of Factory

License under Factory Act

Installed HP

9
10
11

Legal organization
Ownership
Manufacturing process as per NTC
2008
Plan approval No. and date
(------------------ in chronological
order)
Does the factory have a Stability
Certificate?

12
13
14

Permanent Serial no. of Factory

WORKFORCE

15

16

Mention maximum No. of workers employed for any day of the

year
Permanent employees
i) Managers & Supervisors
ii) Workers
a) Workers over 18 years
b) Workers over 14 years but < 18 years
Total Contracts Worker
Daily Wage workers
1

Male

Female

17
18
19
20

21

i)Temporary workers
ii) Casual Workers
i) Apprentices
ii) Trainees
TOTAL of Serial No. 15 to 18
Family members of owner of the factory
a) Paid
b) unpaid
a) Security/Watchman
b) Name of Security Agency/Security Guard Board
c) Mathadi Workers
For Permanent workers, How many years of the services?
Less than one year
1 year to < 5 years
5 years to < 10 years
More than 10 years
Yes,
(if so number)

22
23
24
25

Does the factory employee its own security guards as direct

employees?
Does the factory employee its own mathadi workers as direct
employees?
Does the factory employee its own cleaning staff as direct
employees?
Are any contract workers Inter-State Migrant Workers?

INSPECTIONS
26
27
28

29

30
31
32

What was the date of last Inspection by

a factory inspector?
What was the date of the last spot
safety audit by the Factory Inspector?
What was the date of last occupational,
health and safety Audit conducted by
the Internal Auditor?
What was the date of last occupational,
health and safety Audit conducted by
the External Auditor?
What was the date of the last
examination by a competent person?
Does the factory hold any OSHA 18001, Yes/No
ISO 14001 or other similar certification?
Does the factory have a code of conduct Yes/No
as required by the buyers of the
factories product?

NO

DANGEROUS OPERATIONS AND HAZARDOUS PROCESSES

33
34

Which of the operations among

Dangerous Operations schedule or
conducted in the factory?
I your factory in the list of Industrial
involving hazardous processes as
defined under section 2 (cb) of the
Factories act 1948?

Indicate all operations that are conducted.

If none of the operation listed in the
schedule are conducted, write
If None, write

If YES, which are the hazardous

processes that are carried out of the
factory

STORAGE OF HAZARDOUS SUBSTANCES

35
(i)
(ii)

(iii)

(iv)

Do you store any hazardous chemicals

as listed in schedule 1 annexed to
CIMAH Rules 2003, in you factory? If so,
give the list.
Do you store quantities of hazardous
chemicals equal to or above threshold
limit as listed column no.2 of Schedule 2
annexed to CIMAH Rules 2003, in your
factory? if so, give the list along with
inventory.
Does your factory fall under MAH
category?
If your factory falls under MAH category,
(a) Have you submitted site notification
report?
(b) Have you prepared and submitted ON
site emergency plan?
(c) Have you updated ON site emergency
plan?
(d) Date on the Mock drill along with
scenario, carried out in the year.
Do you store quantities of Hazardous
Chemicals equal or to above threshold
Limits as listed in column 4 of the
schedule 2 annexed in CIMAH Rules
2003, in your factory? If so, give the list
along with inventory.
(a) Have you prepared and submitted
Safety Report?
(b) Have you carried out safety audit
internally in a year? If not
(c) Have you carried out safety Audit
externally?
3

If None, write NIL.

If None, write NIL

Yes/No

Give date of permission.

Give date of permission.
Give date when last updated and submitted.
Give dates of Mock Drill along with scenario,
carried out in the year.

NA

Give date of submission.

Give date and
compliance report.
Give date and
compliance report.

date

of

submission

date

of

submission

SAFETY AND HEALTH

36

37

38

39

40

41
42

Does the factory have written safety and Yes/No

health policy? If YES,
How is this communicated to workers?
(a) Notice Board
(b) Circular
(c) Other
If YES, what language is used?
(a) Marathi
(b) Hindi
(c) English
Does the factory have written safety Yes/No
guide lines for workers?
How is this communicated to workers?
(a) Notice Board
(b) Circular
(c) Other
If YES, what language is used?
(a) Marathi
(b) Hindi
(c) English
Does the factory have an onsite Yes/No
emergency plan?
If YES, evacuation plan is displayed
throughout the factory for all workers to
see?
If YES, is there a regular onsite emergency
mock drill involving evacuation drills?
If YES, what was the date of last mock drill?
Does the factory have safety officers?
Yes/No
If YES, how many as on reporting date?
___________.
If yes, Whether he is a qualified safety
officer as per Rules?
Does the factory have a safety committee Yes/No
member?
If YES, how many workers are member of
safety committee? -05 NOS.
How many management representatives are
members?
04 NOS.
If YES, how often does it meet?-MONTHLY
Does the factory have at least 2 exits on Yes/No
each floor in each building occupies?
Are fire extinguishers placed throughout Yes/No
the factory?
If YES, how many extinguishers
S.No. Type
Capacity
Quantity
1
Foam Type
2
Dry Powder
5kg/2kg
12/06
3
CO2
4 Any other
If YES, how many workers have been
trained to use extinguishers?
06
4

43

Does the factory have First AID Boxes?

Yes/No
If YES, how many throughout the factory?
2 Places
If Yes, how often are they checked for their
contents? Every Months 2 times.

44

Does any worker have a First AID

Certificate?
Does the factory have a HIV/AIDS
Policy?
Does the factory provide workers with
personal protective equipments (PPEs)?

If Yes, How many? No.

45
46

47
48
49
50
51

Yes/No.
If yes, which items are provided?
Head Protection
Foot Protection
Eye protection
Ear protection
Hand protection
Body protection
Respiratory Protection
Other
Yes/No
If Yes, which items?
Yes/No
If Yes, How many non fatal? _____
How many fatal? __________
Yes/No
If Yes, How many non fatal? _____
How many fatal? __________
Yes/No,
If YES, How many __________.

Are worker required to pay protective

clothing for equipment?
Has the factory reported any accident to
Factory inspector during the reporting
period?
Has the factory reported any occupational
diseases to the factory inspector during
the reporting period?
Has the factory reported dangerous
occurrence to the factory inspector during
the reporting period?
Are safety poster displayed in the Yes/No.
factory?

WELFARE FACILITIES
YES
52
53
54

55
56
57
58
59
60

Does the factory provide drinking water for workers?

Does the factory have a crche?
(a) Does the factory have a canteen?
(b) Is the canteen managed by___
(i) Departmentally or
(ii) Through a contractor or
(iii) By Co-Operative society.
Is a lunch room provided?
Does the factory provide a locker for workers?
Is there changing room for workers?
Is there a Rest room or shelter for workers?
Is there an Occupational Health Centre?
Is the occupational Health centre open to members of workers
family?
5

NO

61
62
63
64
65
66
67
68
69
70
71

Is there an ambulance room?

Is there a full- time doctor in attendance?
Is there a part -time doctor?
Is there a full- time nurse in attendance?
Is there a part- time nurse?
Dos the factory have a separate toilets for men and women?
How many latrines for men?
How many urinals for men?
How many latrines for women?
Are the above facilities available for contract workers?
Is there a welfare officer?
If Yes, number of welfare officers?

WAGES AND BENIFITS

72

Are worker
overtime?

required

to

work Yes/No,
If yes, what is the overtime rate of pay?______.
If yes, what was highest number of overtime
Hours worked by a worker last month?
________.

73

a) How many hours per day (without

overtime) do workers work?
8 HOURS
b) How many days are required to 06 DAYS.
work for the worker per week?

INDUSTRIAL RELATION
74
75
76

77

Does the Factory have a written

Policy
against
sexual
harassment?
Does the Factory have a
committee for redressed of
sexual harassment?
Have any sexual harassment
complaints been lodged within
the factory during the reporting
period?
Does the factory operate
suggestion box scheme?

Yes/No
Yes/No
Yes/No
Yes/No,
If yes, how much useful suggestion received during
the periods? _________.
1. How many suggestions were acted upon? ___.
2. How many workers rewarded for suggestion?
_______.
3. How much amount was distributed as reward?
_______________.

78

Employments information

WORKERS

Avg. No.
of
workers
employe
d daily

No. of days worked in a year

Number
of Avg. No.
mandays
of
hours
during
the worked
year
per week

Number of
manhours
worked on
overtime in
year.

Number of
manhours
worked
including
overtime in
a year

Adults

Male
Female
Adolescents
Male
(15-<18 years)
Female
Children
Male
(14-15 years)
Female
TOTAL
See the explanatory note given below.

79

Leave with wages

Numb Num
er
ber
emplo entitl
yed
ed to
WORKE
annu
RS
al
leave
Adults

Num
ber
who
were
grant
ed
leave

Num
ber
of
disch
arge
d
work
ers

Numb
er of
dismi
ssed
worke
r

M
F

Adolesc
ents
(15-<18
years)
Children
(14-15
years)

M
F
M
F

Number
of
workers
who
quit the
employ
ment

Numb
er of
worke
rs
super
annua
ted

No. of
workers
who
died
while in
service

No.
of
workers to
whom
wages in
lieu
of
leave were
paid

80

Accident Details

(a)

Workers employed directly

Permanent
Temporary

Contract
Workers

Total

No. of Fatal Accident

No. of Non Fatal Accident
(b)
Fire
Dangerous Occurrences
No.
of
dangerous
occurrences
(c)
Number
workers
injured

of Number of injured
workers
who
returned to work in
this year

Explosion

Toxic gas release

Number of workers No.

of
injured in previous manyear who joined the days lost
work this year

Collapse
of
building/structure

Number of workers
injured this year but
have not joined during
this year

81
Occupational Disease Details
List of
occupational Occupational diseases No.
of Mandays lost due to
diseases
which
are reported in the reporting workers died occupational diseases
relevant to your factory
period
due to

82
Medical Checks by Certifying Surgeons
Frequency of Dates
of Name of the certifying
health
medical
surgeon who carried
checkups in examination of out
the
medical
you factory
the workers
examination

83

Compensation/EX-gratia Details
Name
Age Monthly
%
Com
of
wages
Disa pens
worker
bility ation

Exgratia
amount
paid

Number
of
workers
examined

Occupational diseases
detected
Type
No.

Whether
Whether
covered
legal heirs of under
ESIC
or
deceased
insured under WC
employed
policy? If details

84
Closure information of factory as per rule 125(2) of M.F.R., 1963
Name of Factory and full address
9

Date of closure
Reason of closure
Nature of closure, whether entire or partial.
Entire/Partial
If partial the shift, section or department
closed.
Number of workers on the muster roll at the
time of closure
Number of workers affected by the closure
85
Re-opening information of factory as per rule 125(3) of M.F.R., 1963
Name of the factory and full address
Date of closure
Numbers of workers affected at the time of
closure
Factory or any shift, section or department
thereof reopened
Number of workers on the muster roll at the
time of reopening
Number of workers re-employed and newly Re-employed employed
Newly employedOTHER
86
87

88

Is the factory a member of

the
Mutual
Aid
and
Response group (MARG).
Has the company engaged
in any other corporate social
responsibility
activities
during the period?

Yes/No
Yes/No
If YES,
What activities?_________________
Who benefited?_________________

Does the factory employ Yes/No

any disabled workers?
If YES, What types of disability?
(e.g. physical, sight, hearing, intellectual?________.
How many men? ___________.
How many women?__________.
If YES, what special assistance and support, if any, has
been provided for them?___________________.

I verify and state that the above information is true and correct to the best of my knowledge
and belief.
Signature of Owner/Manager ______________________

Name- __________________________________
Designation- _____________________________
Explanatory Notes:
10

Date:_____________________.

*1 the average number of workers employed should be calculated by dividing the aggregate
number of attendances on working days (that is, man-days worked) by the number of working
days in year. In reckoning attendance, attendance by temporary as well as permanent
employees should be counted, and all employees should be included, whether they are
employed directly or by or through any agency including contractors. Attendance on separate
shift(e.g. night and day shifts) should be counted separately. Days on which the factory was
closed for whatever cause and days on which manufacturing process were not carried on
should not be treated as working days. Partial attendance for less than half a shift on working
days should be ignored, while attendance for half a shift or more on such day should be
treated as full attendance.
2 For seasonal factories, the average number of workers employed during the working season
and the off-season should be given separately. Similarly the number of days worked and
average number of manhours worked per week during the working and off-season should be
given separately.
**3 The average number of hours worked per week mean the total actual hours worked by all
workers during the year excluding the rest intervals but including overtime work divided by the
product of total number of workers employed in the factory during the year and 52. In case the
factory has not worked for the whole year, the number of weeks during which the factory
worked should be used in place of the figure 52.
4 Every person killed or injured should be treated as one separate accident. If in one
occurrence, six persons were injured or killed, it should be counted as six accidents.
5 In items 24(a), the number of accidents which took place during the year should given. In
case of non-fatal accidents only those accidents which prevented workers form working for 48
hours or more, should be indicated.

11