PROFORMA -2

STATE LEVEL SAFETY AWARDS - MAHINDUSTRY

(41stNational Safety Day Celebration - 4th/5thMarch 2012)

Instructions:

  1. Information shall be furnished for the calendar year 2011.
  2. Enclose supporting documents wherever required insupport of information furnished.
  3. Separate sheets may be used to furnish the additional information.

FACTORY LIC NO. :

1. Name and address of the Factory:

2. Name of the Occupier Manager.:

3. No. of workers in the factory

No. of workers sanctioned as per the license:

No. of workers ordinarily employed:a) Permanent:

b) Contract :

c] Others :

Average no. of workers employed during the year:

4. Brief manufacturing activity

4A. Turn over during the year 2011:

5. Details of Safety, Health & Environment status:

SHE policy : Yes / No (enclose Copy]

Safety Organization: Yes / No (enclose Copy]

Safety Budget (Year-2011): Rs.

SafetyAuditing : Done in the year 2011

Safety Officer Appointed: Yes/No (Wherever Applicable)

Accreditationsobtained in 2011: (OSHAS, ISO, etc.)

Safety awards received in 2011:

(Note: Please enclose all relevant documents.)

5A. Welfare Measures:

a) Rest cum Lunch room provided:

b) Canteen facilities provided:

c) Creche facilities provided:

d) Welfare officer appointed:

e) Ambulance room provided:

f) Factory Medical Officer with paramedical staff appointed.

g) Ambulance van maintained.

5B. Overtime work:

a) Whether exemptions obtained from dept.:

b) Rate of wages paid for Overtime work:

6. Accidentstatistics for the calendar year 2011.

a)No. of reportable accidents (Non-fatal) during the year:

b)No. of serious accidents / Permanent total disability reported.

c)No. of Fatal accidents.

d)Accident frequency and severity rate per 1000 workers :

e)Total no. of man days / man hours worked :

f)No. of man days / man hours lost due to accidents :

g)Longest accident free period:

h)Control measures to prevent accidents :

Accident data for last three years

2008 / 2009 / 2010
Fatal
Serious
Reportable
Non-reportable
Near miss

Note: Submission of Combined Annual Return-2011 is compulsory.

7. Safety and Health Status reports:

a)Suggestions received / accepted / implemented:

b)Amount spent on purchase of Safety equipments

in the year 2011 and percentage of budget utilized.:

8. Medical Examination/surveillanceConducted

a)No. of workers

Permanent workers:

Contract workers:

Others :

b)No. of Occupational health diseases identified.

c)Follow up action.

d)The name and address of the medical officer

conducting suchexaminations

e)Copy of Form-16 to be furnished.

9. Machine guarding.

a)Status report.

b)Amount spent during the year 2011.

10. Fire Prevention.

a)Fire prevention and control systems provided-details

b)No. of fire incidents.

c)No. of persons trained in fire fighting.

Permanent workers:

Contract workers:

11. Safety awareness programmes.

a)No. of training programmes conducted

Inhouse –

Externally-

b)No. of Persons Trained

Category of workers / 2009 / 2010 / 2011
Permanent
Contract
Percentage of workers covered in a year

c)No. of persons deputed for training outside.Permanent/Contract

d)Amount spent on SHE training during the year.

e)Level of awareness on SHE Policy.

f)No. of Training Programmes conducted through Karnataka State Safety Institute (Dept. of Factories and Boilers].

12. House keeping.

a)Status report.

b)Measures adopted.

c)5 S concepts

13. SHE Promotional Activities.

a)Safety committee.Yes / No

b)Workers participation.Permanent workersYes / No Contract workers Yes / No

c)Authority delegated on decision making.Yes / No

d)Chairman of Safety Committee(Designation)

14a) Future action plan / commitment to promote

SHE Policy during the coming year / years.

b) Commitment to promote SHE Policy in the

ancillary Industries/out sourced products

15. Statutory Tests by competent person:

a) Pressure Vessels:

b) Lifting machine and tackles:

c) Power Presses:

d) Centrifugal machines

e) Other machineries/ equipment.

e) Name of the competent person with date of examination.

16. Drinking Water:

a) Source of Water

b) Potability Test

c) Periodicity of Test

d) Agency Conducting Test

e) Cases of infection

17. (a) Details of work-environment monitoring

conducted with specific data and the field

(b) Protocol for follow up action.

18.Whether the On-site Emergency Plan

prepared/updated approved.

19. Whether the hazards involved in the industry along with On-site

Emergency plans have been made Known to the employees, if so give

the methodology, mechanism adopted along with total number of

employees involved. Enclose relevant copies.

20. Whether the MSDS are displayed in respect of all chemical

substances, manufactured, stored, used and handled in the industry.

21. Is there a safety committee constituted and how often meetings are

conducted.

22. Are the Safety Audit, Risk Analysis and Hazop Studies etc., have been

conducted? If so, Specify action taken for the findings/observations of

the Audit.

23.Whether Safety report has been prepared & submitted to dept. (as per

MAHC Rules).

24. Whether Preventive maintenance system is followed.

25. a. No. of on-site emergency mock-drills conducted and their

frequency.

b. Details of public awareness programs conducted.

26. Whether safety manual is prepared and Standard Operating

Procedures are developed.

27. How is the idle shift, holidays managed? Whether the security

personnel are trained in emergency handling.

28. Whether the occupational HealthCenter is being provided? If so,

furnish the details of infrastructure facilities and medical staff.

29.Whether an Ambulance van is provided and maintained along with a

driver, if so furnish the details, if not specify the reason along with the

alternative arrangements made.

30. Additional information, if any,

Date: Signature of Occupier

Place: (Name in block letters)

Contact person from the factory for communication

Name of Factory Manager/HR Manager:

Telephone No/Mobile No.

Email ID:

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Please Note:

Completed applications with all the necessary enclosures/documents shall be sent to

K SRINIVAS,

Dy. Director of Factories,

Bangalore Divn. 4

Room No. 210, II floor. Karmika Bhavan,

Bannerughatta Road, Bangaluru-560029.

Phone: 080-26531205.

Last date for submission: 28-01-2012.