Rule Form XVII Form XVII

FORM-XVII [See rule 72(5) r/w rule 74 ] ANNUAL RETURN

st

FOR THE YEAR .......ENDING 31 December.

Instructions for filling up the Annual Return

Conditions CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020), 2020.

even where one worker was employed during the relevant period.

Applicable to All Establishments - Part-I

A. General Information:

Sl. No. Labour Identification Number From - To- Instructions for filling the column

B(a). Hours of Work in a day

B(b). Number of Shifts

Number of hours in a shift

C. Details of Manpower Deployed

Details Directly employed Employed through Contractor Grand Total

Skill Category HighlyS Skilled Semi- Un- Highly Skilled Semi- Un-Skilled Skilled Skilled Skilled killed Skilled

employed in the establishment during indicated

the year

during the year

(Section 59 of OSH&WC CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020))

engaged

D. Details of contractors engaged in the Establishment:

Sl. No. Name with LIN of the Contractor No. of Contract Labour Engaged

E. Details of various Health and Welfare Amenities provided.

Sl. Nature of various welfare amenities provided Statutory (specify the Instructions for filling

No. statute)

section24(v) of OSH&WC CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020), 2020) and not applicable worker including contract labour were

ordinarily employed

CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020), 2020 and section 24 of the OSH&WC CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020) 2020) and not applicable workers are employed

2a If 2 above is not given than whether Crèches allowance Tick yes or no in the box Reference rule.. on Social Security

under Rule.. of Social Security CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020) given. and not applicable

CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020), 2020) and not applicable wherein more than five hundred workers are

ordinarily employed

CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020), 2020. and not applicable workers or more, factory carrying on hazardous process and

BOCW employing 250workers or more,

and mines employing 100 or more workers.

2020) appointed BOCW 250 or more workers and in case of dock work 500

or more workers are ordinarily employed.

this detail is required to have

data on occupational health.

F. The Industrial Relations: Yes/No and not applicable Instructions for filling

CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020), 2020)

year:

Dismissed Retrenched Discharged /Terminated or Grand

Removed Total

Sl. Reasons Period No. of man-No. /Date days lost

Sl. No. of persons Details of payment No. of workers No. of man-days lost due to lay-off Applies on industrial establishment employing 300 or more workers No. retrenched during paid to retrenched laid off during

the period employees the period

G. Details pertaining to maternity benefit:

No. of female No. of female employees No. of female employees No. of deduction of wages, if any made

employees availed maternity leave paid medical bonus from female employees

H. Details of payment of bonus: Total amount of bonus actually paid Date on which the Bonus paid Sl. No. of employees covered under No. the Bonus provision

I. Details of accidents, dangerous occurrence and notifiable diseases: Total number of Dangerous Total number of cases of Sl. Total number of accidents by which Total number of fatal accidents and Occurrences as defined under Notifiable Diseases specified No. a person injured is prevented from names of the deceased as per Section Section 11 of the OSH&WC in Third Schedule of the CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020),2020 OSH&WC CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020), 2020 along working for a period of 48 hours or 10 of the OSH&WC CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020), 2020. with more as per section 10 of the the details of affected persons OSH&WC CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020), 2020.

J. Man days and production lost due to accidents / dangerous occurrences

Sl. Accident/Dangerous Man days lost Production Lost

No. Occurrence

[See rule 72 r/w rule 74] Part II (For Mines)

A. General information

9 Mine CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020) To be filled for first time

B. Statutory personnel employed in the mine (as on 31st December)

Sl. No. Designation as per CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020) Number of Statutory Persons required Number of Statutory Persons employed 1.

C. Method of Working vis-a-vis Safety Parameters

1 Name of Method (Specify the name) (as per drop down menu)

2 Quantity of mineral Produced in Cu.m./Tonne

3 Quantity of Waste/overburden removed in Cu.m./Tonne

4 Stage of Working (as per drop down menu) Development/Extracti

on/Mixed

5 Permissible Void in Cu.m. For extraction stage

6 Actual Void in Cu.m. For extraction stage

7 Area of overhang For extraction stage

8 Maximum Inflammable gas released in Cu. Meter per ton of coal produced For Development

stage

9 Overall Pit slope For Opencast mines

Individual entry for each Pit

10 Overall dump slope For Opencast mines

Individual entry for each Dump

11 Area of fire in Sq. m.

12 Length of embankment required to be provided against the water body

13 Length of embankment provided against the water body

14 Length of fencing required/provided as per statute

15 No. of opening required to be sealed in case of abandoned mines:

16 No. of Openings sealed in case of abandoned mines:

17 Number of Mock drills conducted and date of same with coverage of employees

18 No. of Oil/Gas wells: under drilling/ under production/ under work over (as per drop For Oil and gas

down menu) mines

19 No. of wells where production discontinued For Oil and gas

mines

20 If Yes to pt. 19 above, Action taken

21 Action Taken in respect of Wells where production has been discontinued For Oil and gas

mines

22 Maximum Quantity of explosive used in any day (in Kgs.) Yes/No/NA For all types of mine 23 Whether Building or Structures not belonging to owner lies within danger zone? For Coal & Metalliferous Mines 24 Aggregate HP/KW of machineries installed/deployed in the mine for the year For all types of mine

D. Medical examinations - Initial/Periodical (IME/PME): During the year, total number of persons including contractual workers:

Particulars Total No. of Persons Undergone IME Undergone PME Declared medically Temporary unfit Given alternate Employment due to Medical unfitness

Terminated on account of being medically unfit

E. Details of Vocational training imparted: Total No. of Persons

During the year, total number of persons including contractual workers:

Particulars Imparted Basic Vocational Training Imparted Refresher Training Imparted special Training

F. Details of Accident, Dangerous Occurrence and Occupational Diseases :

Sl. No. Date of No. of persons killed No. of persons Number of persons injured Nature of Mandays lost received Serious (Excluding Serious Bodily Occurrence Accidents/Dangero Bodily Injury Injury) and thereby prevented from working for a us Occurrences period of 48 hours or more

1.

G. Details of Safety Management Plan:

Sl. no. List of Principal hazards Principal hazard Principal hazard not mitigated Reasons for failure to

H. Mines Rescue Station: (For Belowground Mines Only)

A. For Mine: (To be filled by mine owner)

Mines Rescue Station: (For Belowground Mines Only) (For Rescue Station)

For Mine Rescue Station (To be filled by the Superintendent of the Rescue Station)

Sl. Name of the Mines Distance of the Mine from MRS (in Kms)

No.

Sl. Designation as per Number of statutory Number of statutory

No. CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020) persons required persons employed

Sl. Type of Numbers of Equipment/Apparatus available

No. Equipment/Apparatus

Sl.No. Name of the Nature of Response Time Time taken for Rescue & Action Taken Mine Emergency Recovery (time taken by

rescue services to

attend the

emergency)

Certified that the tables are duly filled in and the information and figures furnished therein are correct to the best of my knowledge.

Signature of Employer/Occupier/Owner/Agent/Manager

Place: Dated:

PART III [See rule 98(9)] ANNUAL RETURN period ending 31st December (to be submitted by the principal employer on Shram Suvidha Portal)

Sl. Month Name and LIN of the Name of Maximum Amount Date of Amount of Date of Remarks address of contractor the work number of paid against payment of the wages payment of the contract wage bill (if wage bill paid directly wages paid contractors labour applicable) (if to the directly to employed to the applicable) contract the contract contractor labour by labour by (including Principal Principal EPF, ESIC, Employer Employer Bonus etc.) (in case the (in case the contractor contractor fails to pay) fails to pay)

Signature of the principal employer

Date:

PART IV (see rule 72(8))

Shram Shuvidha Portal Year: ___ Ministry of Labour and Employment LIN:(Auto-Populated) Self-Declaration formDefined in rule 2(b): FORM means FORMS annexed in Annexure VII to these rules for EPFO/ESIC Contribution

PAN No:

EPF CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020) No. (Auto-Populated)(Editable): ESI CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020) No.(Auto-Branch CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020) Nos. (Auto- Populated)(Editable): Populated)(Editable): Sub CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020) Nos. (Auto-Populated) (Editable):

Statement of salary/wages and contribution in r/o of EPFO

1 2 3 4 =(2+3) 5 6 7 8=(5+7) 9 10 11 12=(9-10) 13

Month Total No. of Total no. of Total no. of Total Wages Total EPF Total Wages Total wages Total Total Date of Balance to No. of & employees employees employees paid to Wages paid to paid to paid to all Contribution contribution payment be paid employees Year eligible for not eligible employed employees employees employees employees Payable paid to whom membership for eligible for eligible under not eligible (Based on column dues to be under SS membership membership SS under SS 6) paid CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020)/Scheme under SS under SS CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020)/scheme CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020)/scheme CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020)/scheme CodeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020)/scheme

04/20.. 05/20.. 06/20..

07/20.. 08/20.. 09/20.. 10/20.. 11/20..

12/20. .

01/20. .

02/20. .

03/20. .

· Upload Salary sheet of contribution details of all members as per Form-VIIIB(Register of Wages, Overtime & Dedcution)

Details of Employees non-enrolled but eligible to be member: Date of Date of Date of Exit Wages paid Sr. No Name of Employee Gender Aadhaar Number Father's Name Birth Joining (If already left)

Contractors details: EPF codeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020) No. ESI Nature of Maximum Number Total payment made during the FY codeDefined in rule 2(a): Code means the Occupational Safety, Health and Working Conditions Code, 2020 (37 of 2020) work of employees S.No. Name & No. employed during Address of the any day contractor

<*contractor details may be pre-filled from CLC Licence data if available with option to add other contractors>

Details of tax benefit claimed by employer by way of contribution towards a recognized provident fund or an approved superannuation fund u/s 36(1)(iv) of Income Tax Act:

Financial Year Contribution Tax benefit

UPLOAD DCOUMENTS:

S. No. DOCUMENT Name <upload field in portal>

*mandatory field

(Signature of the Employer/authorized representative)