Draft

APPLICATION FORM
NATIONAL SAFETY COUNCIL OF INDIA (NSCI)
AWARDS-2018
FOR SAFETY OFFICERS IN FACTORIES

AFFIX
PASSPORT SIZE
PHOTO

I. Candidate Information:

1 Full Name

2 Date of Birth & Age

3 Address for Communication

4 Contact No

5 Contact E mail ID

6 Are you a Member of NSC or any

safety professional body?
If yes, give Membership Number

7 Educational Qualification
(General & Safety Related)

8 Total years of Experience

9 Total years of Experience in the

present Organization as Safety
officer

10 Designation of Posts during

assessment year

11 Whether your employment as

Safety Officer has been notified to
DISH under the Factories Act and
state Rules?

12 Have you received any Awards in

the past three years for your
excellence in the field of Safety?
If yes, provide the details of such
Institution and the awards in brief.

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II. Information of Factory

1 Name of the Factory and

Registration Number

2 Address of the Factory

3 Is your factory a Corporate Member

of NSC ?
If yes, give NSC Membership
Number

4 Name, Designation, Address and

contact number of the person
approving the Application form on
behalf of the Organization

5 Provide organogram of your factory

indicating your reporting
6 Brief description of process /
operation

7 Is your factory covered under

Section 2 (cb) OR notified by state
government under Section 87 of the
Factories Act. If yes provide the
details of Hazardous Process /
Dangerous Operation carried on in
your factory

8 Is your factory classified as Major

Accident Hazard (MAH)
installation/factory?

If yes, provide the names of

chemicals handled / stored with the
details on type of storage and
quantity

9 Is your organization a member of

Mutual Aid Response Group

10 Have your organization received any

Awards in the past three years in the
field of Safety?
If yes, provide the details of such
Institution and the awards in brief.

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III. Safety performance of factory :

1 Total number of employees Employee 2017 2016 2015

including contract worker Regular
during assessment year Contract
Total

2 Accident details 2017 2016 2015

2.1 Number of Fatal accidents

2.2 Number of Total Disablement

(TD)

2.3 Total man days lost on

account
of Fatal accidents & Total
disablement

2.4 Total number of reportable

Accidents (excluding Fatal &
total disablement cases)

2.5 Total No. of man-days lost

due to reportable Accidents
(excluding Fatal & total
disablement cases)

2.6 Total number of dangerous

occurrence

2.7 Total number of first aid

injuries

2.8 Total number of near miss

incidents

2.9 Has there been any

Prosecution (launched for
accident occurred during the
assessment period) /
Conviction for contravention
with regard to any Safety &
Health provisions under the
Factories Act and Rules
framed there-under?

2.10 Has there been any

prosecution/conviction for
breach of any provision under
the Environment (Protection)
Act, 1986 and Rules framed
there under

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IV. Performance of safety officer in Safety management:

1 Explain your contribution in developing safety management system in your factory.

2 Total number of in house safety training programmes organized/conducted by you. Please provide
following details

years Safety training topic No of training No of employee benefited

programmes
2017
2016
2015

3 Total No. of safety training programmes organized/conducted with the help of outside agencies.
Please provide following details

years Agency Safety training topic No of training No of employee

conducted benefited
2017
2016
2015

4 Plant safety inspections conducted by you

years No. of Plant safety No. of Remedial No. of Remedial measures

inspections measures suggested implemented
2017
2016
2015

5 Give your contribution in developing Safe Operating procedures (SOPs) including details thereof.

6 safety studies / surveys / audits organized / conducted by you

years No. of safety studies / No. of points identified No. of points corrected
surveys / audits
2017
2016
2015

7 Mock drills arranged/conducted in your factory.

years No. of mock drill conducted No. of points observed

2017
2016
2015

Explain your role in such mock drill.

8 Explain your role in accident reporting, investigation and analysis.

9 Number of Occupational Health and Safety survey conducted/arranged (on Noise, heat,
ventilation, illumination etc.). Explain your role in details

10 Explain your contribution in Hazard identification & risk assessment using technique like HAZOP,
JSA, QRA etc.
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11 Safety committee meetings held during assessment period

Safety committee 2017 2016 2015

No. of safety committee held
1. No. of suggestions by the committee
No. of items complied with

12 Details of Safety Promotional activities like campaigns competitions, exhibition etc.,

organized/conducted during assessment period

V. Provide brief notes on your achievements on the following:

1. New initiatives and systems developed and established by you in the last three years.

2. Innovative methods implemented towards Occupational Health & Safety and benefit of it to
organization.

3. Activities related to accident prevention in last 3 years

4. Describe methodology for selection of PPE and their effective implementation

5. Give any other details which make you to feel that you are one of the best safety officer

VI. Contribution at International/national/Local level

1. Provide the details of Presentation / Technical publications on safety (National/international level)

2. Professional contribution (Safety, Health & environment) to public services/educational institutes/

NGOs etc.

3. Provide information regarding your role in operation of MARG in your area if any

VII. Payment details of participation fees:

D.D. / Cheque No._____________________ Dated______________

Bank Name_______________________________________________________________

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VIII. Certificate

Part A

I hereby declare that the particulars given in this application including the documents are true and correct

to my knowledge.

Date: Signature of the Applicant

Place: Name:

Designation:

Part B

I hereby certify that the applicant Mr______________________________ is working in our organization for

the past_____________________ years and the particulars provided by him in this application including

the documents are true and correct to my knowledge and belief.

Date: Signature of the Factory Occupier / Manager

Place: Name:

Designation:

Factory Seal:

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IX. Affidavit

(On Non-Judicial stamp paper of Amount Rs. 100/-)

I, Mr / Mrs / Ms -----------------------------------------------------------------------------
S/o / D/o ----------------------------------------------------- Residing at --------------------
-------------------------------------------------------------------------------------------------------
--------------------------------------------------- hereby declare that the information
provided in application form and attachments are true & correct. I have
taken initiatives to improve Safety / Health / Environment in the work
place located at -----------------------------------------------------------.

I hereby declare that I shall accept the judgment of the Assessment

Team and shall not raise any dispute through any legal or social forum.

The Application is certified by Mr. ------------------------------------------------------

--------------------- Designation ----------------------------------- after physical on
spot verification and evaluation.

The affidavit is signed by me on the day of ------------------------------------------

at ----------------------------------------------------------------------------------------------------

Date: ___________ Name: ____________________________

Place: ___________ Signature: _________________________

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