FORM XXIII [(See rule 53(5)]
ANNUAL RETURN
st
FOR THE YEAR .......ENDING 31 December
Single annual integrated return to be filed online under the Occupational Safety, Health and Working Conditions Code, 2020(37 of 2020), the Code on Industrial Relations, 2020(35 of 2020), the Code on Social Security, 2020(36 of 2020), and the Code on Wages, 2019(29 of 2019) and the rules made there under.
Instructions for filling up the Annual Return
(1) This return shall be filled-up and furnished on or before the 28th or 29th day of February every year.
(2) This return consists of two parts i.e. Part-I , which shall be filled up by all establishments.
(3) Part-II shall be filled-up only by the establishments that are Mines in addition to Part-I.
(4)The terms establishment and mines shall have the same meanings as assigned to them in the
respective Codes.
(5)This return shall be filled-up in the case of contractor or manpower supplier who has engaged
more than 50 workers and in the case of mines, even where one worker was employed during the relevant period. Applicable to All Establishments - Part-I
A. General Information:
Sl. Labour From Instructions for filling the column N Identification EPFO, ESIC, MCA, MoLE (LIN) o. Number - To- Period should be calendar year
1. Period of the Return
2. Name of the Establishment
3. Email ID (employer)
4. Telephone No. (employer)
5. Mobile number (employer)
6. Premise name Sub-locality
7. District
8. State 9. 10 Pin Code . 11 Geo Co-ordinates . 12 Hours of Work . in a day B(a). Number of Shifts
B(b).
Number of hours in a shift C. Details of Manpower Deployed
Directly employed Employed through Contractor Gran d Details Tota l
Skill HighlySkill Skille Semi- Un- Highl Skille Sem Un-
Category ed d Skille Skille y d i- Skille
d d Skille Skill d
d ed
(i) M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T
Maxim
um No. of employees employed in the establishment in any
day during the
year
(ii) No. to be M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T
Avera indicated
ge No. of employees employed in the establishment during
the year
(iii) Maximum M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T M/F/T
number of
Migrant
Worker during
the year
(Section 59 of
OSH&WC
Code)
(iv) Number M/F/T M/F/T M/F/T M/F/T
of fixed term
employee
engaged
D. Details of contractors engaged in the Establishment:
Sl. Name with LIN of the No. of Contract Labour Engaged
No. Contractor
E. Details of various Health and Welfare Amenities provided.
Sl Nature of various welfare Statutory Instructions for filling
. amenities provided (specify the
No statute)
.
1. Whether facility of Canteen Tick yes or no in Applicable to all establishments wherein hundred
provided (as per section24(v) of the box and not or more worker including contract
OSH&WC Code, 2020) applicable labour were
ordinarily employed
2. Crèches(as per section 67of Tick yes or no in Applicable to all establishments where fifty or
Code on Social Security Code, the box and not more workers are employed
2020 and section 24 of the applicable
OSH&WC Code 2020)
2 If 2 above is not given than Tick yes or no in Reference rule.. on Social Security a whether Crèches allowance the box and not applicable under Rule.. of Social Security Code given.
3. Ambulance Room(as per section Tick yes or no in Applicable to mine, building or other construction 24(2)(i) of OSH&WC Code, 2020) the box and not work wherein more than five hundred workers are
applicable ordinarily employed
4. Safety Committee (as per section Tick yes or no in Applicable to establishments and factories 22(1) of OSH&WC Code, 2020. the box and not employing 500 workers or more, factory carrying
applicable on hazardous process and BOCW employing
250workers or more,
and mines employing 100 or more workers.
5. Safety Officer (as per section No. of safety In case of mine100 or more workers, in case of 22(2) of OSH&WC Code, 2020) officers appointed BOCW 250 or more workers and in case of dock work 500 or more workers are ordinarily employed.
6. Qualified Medical Practitioner (as No. of There is no specification for minimum number of
per section12 Qualified Qualified Medical Practitioner employed in
(2) of OSH&WC Code 2020. Medical establishment. However, this detail is required to
Practitioner have
appointed. data on occupational health.
F. The Industrial Relations: Instructions for filling
1. Is the Works Committee has been functioning.(Section 3 of IR Yes/No and Industrial establishment in Code, 2020) not applicable which 100 or more workers are employed
(a) Date of its constitution. Yes/No and
2. Whether the Safety Redressal Committee constituted (Section 4 not applicable Industrial establishment of IR Code, 2020) employing 20 or more workers
3. Number of registered Unions in the establishments.
4. Whether any negotiation union exist(Section14 of IR Code,2020) Yes/No
5. Whether any negotiating council is constituted (Section 14 of IR Yes/No Code, 2020)
6. Number of workers discharged/dismissed, retrenched or whose services were
terminated during the year:
Dismissed Retrenched Discharged Grand
/Terminated Total
or Removed
7. Man-days lost during the year on account of
Sl. Reasons Period No. /Date of No. man-days
lost
(a) Strike
(b) Lockout
8. Details of retrenchment / lay off
Sl. No. of persons Details of payment No. of No. of man-days Applies on industrial lost due to lay-off establishment No. retrenched during paid to retrenched workers laid employing 300 or more workers the period employees off during
the period
G. Details pertaining to maternity benefit:
No. of femNaole. oefmfpemloayleees No. of female No. of deduction of wages, if any made from female employees availed employees paid employees
maternity leave medical bonus
H. Details of payment of bonus: Total amount of bonus Date on which the Bonus paid Sl. No. of employees covered actually paid No. under the Bonus provision
I. Details of accidents, dangerous occurrence and notifiable diseases:
Sl. Total number of accidents by Total number of fatal Total number of Total number of cases of Notifiable No. which a person injured is accidents and names of Dangerous Diseases specified in Third Schedule of prevented from working for a the deceased as per Occurrences as the OSH&WC Code, 2020 along with period of 48 hours or more as Section 10 of the defined under the details of affected persons per section 10 of the OSH&WC Code, 2020. Section 11 of the
OSH&WC Code, 2020. OSH&WC
Code,2020
J. Man days and production lost due to accidents / dangerous occurrences
Sl. Accident/Dangerous Man days lost Production Lost
No. Occurrence
Part II (For Mines)
A. General information
1. Establishment Name
2. Name of Company/ Name of Owner
3. Type of organization (drop down) PSU Central/ PSU State/ Private/
4. Type of ownership (drop down) Firm/Association/Individual/Partnership/Company
5. Type of Mineral (drop down) Coal/Metal/Oil
6. Name of Mineral Belowground/ Opencast/
7. Type of Mine (drop down) Aboveground/Mixed/OffShore/OnShore
8. Date of opening 9 Mine Code To be filled for first time
10. Date of closing (if any)
11. Date of reopening (if any) To be filled for first time
12. Depth of working in mts. NA/ Calendar to be given
NA/ Calendar to be given
Maximum Depth: Minimum Depth:
B. Statutory personnel employed in the mine (as on 31st December)
Sl. No. Designation as per Code 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/Extraction/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 For per ton of coal produced 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 For Oil and gas mines 15 No. of opening required to be sealed in case of abandoned mines: For Oil and gas mines 16 No. of Openings sealed in case of abandoned mines: For Oil and 17 Number of Mock drills conducted and date of same gas mines with coverage of employees For all types of mine 18 No. of Oil/Gas wells: under drilling/ under For Coal & production/ under work over (as per drop down Metalliferous menu) Mines For all types 19 No. of wells where production discontinued of mine
20 If Yes to pt. 19 above, Action taken
21 Action Taken in respect of Wells where production has been discontinued
22 Maximum Quantity of explosive used in any day (in Kgs.)
23 Whether Building or Structures not belonging to Yes/No/NA owner lies within danger zone?
24 Aggregate HP/KW of machineries installed/deployed in the mine for the year
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: During the year, total number of persons including contractual workers:
Particulars Total No. of Persons Imparted Basic Vocational Training Imparted Refresher Training Imparted special Training
F. Details of Accident, Dangerous Occurrence and Occupational Diseases :
(1) Details of Accidents and Dangerous Occurrences:
Sl. Date of No. of persons No. of Number of persons Nature of Mandays No. Accidents/Dangerous killed persons injured (Excluding Occurrence lost 1. Occurrences received Serious Bodily
Serious Injury) and thereby
Bodily Injury prevented from
working for a period
of 48 hours or more
Sl. No (2) Details of Occupational diseases: No. of cases 1 Notified Disease
G. Details of Safety Management Plan:
(a) Safety Management Plan Prepared: (Yes/No/NA)
(b) Date of Submission : Date
(c) Last date of review of Safety Management Plan: Date (d ) Principal Hazards Identified:
Sl. no. List of Principal Principal hazard Principal hazard not Reasons for failure
1. 31st to mitigate the same hazards identified Mitigation date mitigated till
December
H. Mines Rescue Station: (For Belowground Mines Only)
A. For Mine: (To be filled by mine owner)
(i) Address of the Rescue Station with Geo-coordinates serving the mines;
(ii) Distance of the Rescue Station from mine opening; -----(in KM)
(iii) Whether a mine Rescue Station has been established by the mine ? (Yes/No)
Mines Rescue Station: (For Belowground Mines Only) (For Rescue Station)
For Mine Rescue Station (To be filled by the Superintendent of the Rescue Station)
(i) Name of the owner of the mine at which the Mine Rescue Station is located:
(ii) Address of MRS:
(iii) Name of the Superintendent :
(iv) Details of the mine served by the Rescue Station:
Sl. No. Name of the Mines Distance of the Mine from MRS (in Kms)
(v) Details of Personnel Deployed at Rescue Station;
Sl. No. Designation as per Code Number of statutory persons Number of statutory persons
required employed
(vi) Details of Equipment/Apparatus :
Sl. No. Type of Numbers of Equipment/Apparatus available Equipment/Apparatus required
(vi) Particulars of Emergency Attended:
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)
(vii) Additional Information :
(a) Number of Rescue Rooms :
(b) Number of Rescue Trained Persons Required :
(c) Number of Rescue Trained Person available :
(d) Whether Canteen facility exist or not? ( Yes/No):
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 ANNUAL RETURN period ending 31st December (to be submitted by the principal employer on Shram Suvidha Portal)
1. Name of the principal employer:
2. Name of the establishment:
3. Registration number (LIN) of the establishment:
4. Details of the Contractors, wages paid, etc.:
Sl Mont Name LIN of Nam Maximu Amount Date of Amount Date of Remar
.h and the e of m paid payment of the payment ks
address contract the number against of wage wages of
of the or work of wage bill bill paid wages
contracto contract (if (if directly paid rs labour applicabl applicabl to the directly employe e) to the e) contract to the d contracto labour contract
r by labour
(includin Principa by
g EPF, l Principa
ESIC, Employ l
Bonus er (in Employ
etc.) case the er (in
contract case the
or fails contract
to pay) or fails
to pay)
Signature of the principal employer
Date:
PART IV
Shram Shuvidha Portal Year: ___ Ministry of Labour and Employment Self-Declaration form for EPFO/ESIC Contribution
PAN No:
LIN:(Auto-Populated)
EPF Code No. (Auto-Populated)(Editable): ESI Code No.(Auto-Populated)(Editable): Sub Code Branch Code Nos. (Auto- Nos. (Auto-Populated)(Editable): Populated)(Editable):
Statement of salary/wages and contribution in r/o of EPFO
12 3 4 5 6 7 8=(5+ 9 10 11 12=( 13 7) 9- =(2+3) 10) Bal No. Mo Total Total Tota Total Total Total Tota Total Total Da anc of nth No. of no. of l no. l Contr contri te e to empl & emplo emplo of Wages EPF Wages wag ibutio bution of be oyee Ye yees yees empl es n paid pay pai s to ar eligibl not oyee paid to Wages paid to paid Payab d who s to all le me e for eligibl empl employ paid to emplo empl (Based nt m memb e for oyed oyee on dues ership memb ees employ yees s column to be under ership 6) paid SS under eligible ees not Code/ SS Sche Code/s for eligibl eligibl me cheme 04/20 membe e e .. rship under under 05/20 .. under SS SS
06/20 SS Code/s Code/s .. Code/s cheme cheme 07/20 .. cheme
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:
Sr. Name of Gender Aadhaar Father`s Date Date Date of Wages paid Exit(If No Employee Number Name of of already left) Birth Joining
Contractors details:
S.No. Name & EPF code ESI Nature Maximum Total payment made during the FY of Number of Address No. code work employees employed of the No. during 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>
1. Balance Sheet* <upload field for Balance Sheet of the financial
2. Form 26AS* year>
3. Form 26Q* <upload field for Form 26AS of the financial year> <upload field for Form 26Q of the financial year>
*mandatory field
(Signature of the Employer/authorized representative)
*Section 36(1)(iv) of Income Tax Act:
any sum paid by the assessee as an employer by way of contribution towards a recognised provident fund or an approved superannuation fund, subject to such limits as may be prescribed for the purpose of recognising the provident fund or approving the superannuation fund, as the case may be; and subject to such conditions as the Board may think fit to specify in cases where the contributions are not in the nature of annual contributions of fixed amounts or annual contributions fixed on some definite basis by reference to the income chargeable under the head "Salaries" or to the contributions or to the number of members of the fund;