KARNATAKA FACTORIES RULES, 1969
FORM20
[FORM 20]
(SEE Rule 134 (1)]
COMBINED ANNUAL RETURN
Year ending: 31-12-20……………..
Factory License No…………………
(i)
(ii)
(iii)
(iv)
(v)
(vi)
1.
2.
3.
4.
5.
6.
Form 20, Rule 134, the Karnataka Factories Rules, 1969
Form XXV, Rule 82(2), the Contract Labour (Regulation and Abolition ) (Karnataka) Rules,
1974
Form III, Rule 22 (4), the Karnataka Minimum Wages Rules, 1958
Form D, Rule 5, the payment of Bonus Rules, 1975
Form IV, Rule 20, the Karnataka Payment of Wages Rules, 1963
Forms K, Land M, Rule 16 the Karnataka Maternity Benefit Rules, 1963
Name of the Factory / Establishment
Full Postal Address
Location
Address
Tel.
Fax
E-mail
Name and Residential Address of the Person / Principal Employer responsible for conduct and
control of the business:
Name
Designation
Residential Address
Telephone
(O)
(R)
Mobile
E-mail
Name and Residential Address of the Occupier and Manager
Name
Designation
Residential Address
Telephone
(O)
(R)
Mobile
E-mail
Date of commencement of
manufacturing business
Nature / Type of Industry / Establishment
7.
Particulars of products Manufactured / services
rendered
Name of the
Annual
Quantity
Product / Services
Installed
manufactured
Capacity
(i)
Percentage
achieved
Value
(ii)
(iii)
(iv)
(v)
8.
Does the factory carry on Hazardous Process Yes / No
under Section 2(CB) of the Factories Act,
1948
If yes(i) Whether Health And Safety policy
Yes / No
prepared and published
(ii) Whether Occupational Health Center
Yes / No
provided
(iii) Whether Medical Officer Appointed
Yes / No
(iv) Whether Ambulance Van provided
Yes / No
9.
(a) Particulars of Employment:
No. of
No. of persons on No. of days No. of man days
persons on roll as on 31-12- the factory
worked during
roll as on
20…..
worked
the Year- Men /
1-1-20…
Women / Total
(1)
(2)
(3)
(4)
No. of man
hours worked
including OT
during the year
Men / Women
Total
(5)
Total Amount of
salary / wages paid
including OT wages
and allowances
(6)
(b) Average number of employments during the year:
Men
Women
Without permanent / partial / total
disablement:
(b) With permanent / partial/ total disablement
Number of employees involved in
accidents which either immediately or later
within 7 days resulted in death:
(a)
(v)
Total
(c) Number of employees discharged, dismissed, terminated, retrenched, resigned or retired during the
year
10. Particulars of earned leave with wages:
Total No. No. of
No. of
No. of
No. of employees
No. of employees
of persons employees
employees employees discharged, dismissed, paid wages /
employed eligible for eligible for availed/
terminated,
salary in lieu of
earned
earned
granted
retrenched, resigned
earned leave
leave
leave
earned
or retired during the
leave
year
(i) Men
(ii) Women
11
(a) Safety and Welfare Officers:
Number of Officers required to be appointed
(i)
(ii)
Number of officers actually
appointed
Safety Officers as
per Section 40-B of
the Factories Act
Welfare Officers as
per Section 49 (1) of
the Factories Act
(b) Whether the following welfare measures are provided ?
(i)
Ambulance room as per Section 45(4)
Yes / No
(ii)
Canteen as per Section 46(1)
Yes / No
(iii)
Whether the canteen is run departmentally
Departmentally / Contractor
or through contractor:
(iv)
Creche as per Section 1
Yes/No
(v)
Shelters, rest rooms and lunch rooms as per Yes/No
Section 47(1)
12. Particulars of Accidents , Man days lost and others:
(i)
Total number of accidents that have
taken place in the year
(ii)
Number of employees involved in such
accidents
(iii) Total number of man days lost in such
accidents
(iv)
Number of employees returned to work
within 48 hours of the accidents
(v)
Number of employees returned to work
after 48 hours of the accident (reportable
accidents)
13
1.
2.
3.
4.
Particulars of Maternity Benefits
Total No. of women workers who worked for a period of 160
days in the last 12 months immediately preceding the date of
delivery
No. of women workers discharged / dismissed in the last 12
months
No. of women workers for whom pre-natal confinement and
post-natal confinement is provided by the employer with free of
cost
No. of women workers died
(a) Before delivery
(b) After delivery
Leave / additional leave details:
Item
No. of Women
applied for leave
Leave sanctioned
Leave Reject
Miscarriage
Illness (additional
leave under section
(10)
Maternity benefit paid:
Item
No. of Claims
Received
No. of leave
sanctioned
No. of claims
rejected
Total benefit paid in rupees
Confinement
Miscarriage
Illness
Medical Bonus
14. Particulars of deductions made from salary (wages):
No. of employees involved
(i)
(ii)
(iii)
(iv)
Fines
Damages/Loss
Breach of contract
Others
Total
Total amount of deduction made
15. Payment of bonus paid during the years:
No of employees eligible
for bonus
16. Contract Labour :
Names and
Period of
Address of the
Contract
Contractors
From / To
Percentage of bonus /ex
gratia declared
Nature of
Work
Total amount of bonus/
ex gratia paid
No. of
persons
employed
Max. No. of
contract
workmen
employed on
any day
during the
year
Date of payment
No. of days
worked
No. of Man
days worked
(i)
(ii)
(iii)
(iv)
Total
Certified that the information furnished above is, to the best of my knowledge and belief, correct.
Signature of Employer /Occupier /Manager
Dated:
Name…………………………
Place:
Designation……………………