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FORM - 18 Format

1) The document is a report form for reporting accidents and dangerous occurrences at a factory to the Employees' State Insurance Corporation. 2) It requests information such as the factory name and address, details of the accident/occurrence including location, injuries sustained, and cause of injury, and witness details. 3) The manager or occupier of the factory must sign the completed form, certifying the details are correct to the best of their knowledge.

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Balamurugan Balasubramanian
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675 views

FORM - 18 Format

1) The document is a report form for reporting accidents and dangerous occurrences at a factory to the Employees' State Insurance Corporation. 2) It requests information such as the factory name and address, details of the accident/occurrence including location, injuries sustained, and cause of injury, and witness details. 3) The manager or occupier of the factory must sign the completed form, certifying the details are correct to the best of their knowledge.

Uploaded by

Balamurugan Balasubramanian
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
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FORM No.

18
(Prescribed under rule - 96)

REPORT OF ACCIDENT INCLUDING DANGEROUS OCCURRENCE


Employees State Insurance Corporation Employer’s Code number ………………

Registration Number ………………………………………………………………………..

License Number
Name and Address of Local
Employees Local Employees
State Insurance Corporation
Office

National Industrial Classification


Code No.
(as given in the license)

1. Name and address of factory

2. Name, address and telephone


number of the occupier

3. Nature of industry
(as given in the license)

4. Date, shift and hour of accident or


dangerous occurrence

5. Department / section and exact


place where the accident
or dangerous occurrence took place

6. (a) Description of the accident or dangerous


Occurrence (indicating type) that took place

(b) Whether it involves explosion ………………….; fire ……………………..

emission of toxic substance(s) ………………..substance (s)

emitted………………
7. Total number of persons injured or killed
Number of persons injured Number of persons killed
Inside the factory Outside the Inside the factory Outside the
factory factory

NOTE : If any person outside the factory premises is injured or killed


In the accident or dangerous occurrence, please furnish the
Information to the extent available

8. Particulars of persons injured / Killed


(a) Name :
(b) Age :
(c) Sex :
(d) Serial Number in the register :
of adult workers
(e) Address :
(f) Precise of adult workers :
(g) Nature of job :

9. Cause of injury
Explosion ……………………….. fire ……………………..
Emission of toxic substance ……………………………
Others ………………………………………….(Please specify)
10. Particulars of injury
(a) Fatal (Time and date of death :
(b) Non – fatal (if serious, give the extent of injury such as loss of
lime / sight and hearing, fracture, permanent impairment, severe
burns)
(c) 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 )
11. (a) State exactly what the injured person was doing at the time
of accident or dangerous occurrence

(b) Does this work fail in the category of hazardous or dangerous process
Or operations (please tick mark

Hazardous

Dangerous process or

12. (a) Hour at which the injured person started work on the day of
Accident or dangerous occurrence

(b) Whether wages in full or part are payable to him for the day of accident
or dangerous occurrence
13. In case the accident or dangerous occurrence took place while travelling
in employer’s transport, state whether

(a) The injured person was travelling as a passenger to and from


his place of work

(b) The injured person was travelling with the express 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 or
arrangements made with the employer

(d) The vehicle is being operated in the ordinary course of public


transport services

14. In case the accident took place while meeting emergencies state
(a) Its nature
(b) Whether the injured person at the time of accident was employed
for the purpose of his employer’s trade of business in or about
the premises at which the accident took place

15. (a) Physician, dispensary or hospital from whom or in which


Injured person has received or is receiving treatment :
(b) name of dispensary or panel doctor elected by the injured person

16. Names and addresses of the witnesses (1)

(2)

17. Cause of accident or dangerous occurrence

I certify that to the best of my knowledge and belief, the above


Particulars are correct in every aspect

Signature of Manager / Occupier


Date : Name (in Block letter)
Address and Telephone No.
To be completed by the Inspector

1. Date of receipt of the report :

2. District :

3. Date of investigation :

4. (a) Number allotted to accident involving


Injury and / or death

(b) Number allotted to dangerous occurrence


Involving reportable injury and / or death

(c) Number allotted to the dangerous


Occurrence not involving
injuries and / or death

(d) Number allotted to “Major Accident”


Not involving reportable
injuries and / or death

5. Classification of accident
(a) Cause wise (Give code)
(b) Industry wise (Give National Industrial Classification-Code)
(c) Dangerous operation wise
(Give Schedule Number under rule 95)
(d) Occupation wise ( National Classification of Occupation- Code Number )

6. Result of investigation

7. Remarks, if any

Date : Signature of the Inspector


Name (in block letters)

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