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Form 21-Accident Form-NKIL

This document is a report template for inspectors of factories to record details of accidents involving injuries or fatalities. It includes sections for the date of the report, classification of the accident, particulars of the injured or killed persons, and results of the investigation. The document also outlines the necessary information regarding the nature of the injury, circumstances of the accident, and treatment received.

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KALPESH PATEL
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95 views3 pages

Form 21-Accident Form-NKIL

This document is a report template for inspectors of factories to record details of accidents involving injuries or fatalities. It includes sections for the date of the report, classification of the accident, particulars of the injured or killed persons, and results of the investigation. The document also outlines the necessary information regarding the nature of the injury, circumstances of the accident, and treatment received.

Uploaded by

KALPESH PATEL
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

(To be completed by the Inspector of Factories)

1. Date of receipt of the report :


2. District :
3. (a) Number allotted to accidents involving injury and /or fatality
(b) Number allotted to dangerous occurrence involving reportable injury and/or fatality.
4. Date of investigation

5. Classification of accident

(a) Cause wise (Give code)

(b) Industry wise (Give *NIC-Code)

(c) Dangerous operation wise (Give schedule


number under Section 87)
(d) Hazardous process-wise Section 2(cb)

(e) Occupation wise (NCO-Code Number)

6. Result of investigation

7. Remarks, if any

Signature of the Inspector


Name (In block letters)

Date :

*National Industrial Classification (NIC)


Annexure
Particulars of persons injured, killed
1. Particulars of injured/killed person
a) Name
b) Age
c) Sex
d) Serial Number in the register
of adult workers
e) Address
f) Precise occupation
g) Nature of job
2. Cause of injury Explosion ……… ……………. Fire …………

Emission of Toxic substance ………… Others ………..……. (Please specify)


……….
3. Particulars of injury
a) Fatal (time and date of death)
b) If serious, give the extant of
injury such as loss of
limb/slight & hearing, fracture,
permanent impairment,
severe burns)
c) State whether the injured
person was disabled for more
than 48 hours.
d) Location of injury (i.e. part of
body such as right leg, left
hand, left eye, etc, injured.
4. a) State exactly what the injured
person was doing at the time
of accident or dangerous
occurrence
b) Does this work fall in the
category of Hazardous /
dangerous process of
operations (place mark () in
the box.
Hazardous process ……………………
…….
Dangerous process/operation ……………………
….
5. a) Hour at which the injured person started work on the day of accident or dangerous
occurrence.:
b) Whether the wages in full or part are payable to him for the day of accident or
dangerous occurrence.:
6. In case an accident or dangerous occurrence took place while traveling in the
employer’s transport, state whether
a) The injured person was
traveling as a passenger to and
from his place of work
b) The injured person or implied
permission of his employer
c) the transport is being operated
by or on behalf of the employer
or some other person by whom
it is provided in pursuance of
arrangements made with the
employer
d) the vehicle is being/not being
operated in the ordinary course
of public transport service
7. In case the accident took place
while meeting emergencies, state
a) Its nature; and
b) Whether the injured person at
the time of the accident was
employed for the purpose of
his employer’s trade or
business in or about the
premises at which the accident
took place
8. a) Physicians, dispensary or
hospital from whom or in which
injured person received or is
receiving treatment
b) Name of dispensary/panel
doctor selected by the insured
person

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