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  • Accident Book

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    Madhu Rajagopalan
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    1) This document appears to be an accident report form containing fields to record details of workplace injuries, including the name and address of injured employees, their occupation and insurance details, date and time of injury, cause and nature of injury, and witness information. 2) The form is used to document workplace accidents as required by the Employees' State Insurance Corporation regulation and contains 18 fields to record injury details and ensure proper reporting of incidents. 3) Witness information is also collected, including their names, addresses, occupations, and signatures to validate accident reports entered in the log.

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    1) This document appears to be an accident report form containing fields to record details of workplace injuries, including the name and address of injured employees, their occupation and insurance details, date and time of injury, cause and nature of injury, and witness information. 2) The form is used to document workplace accidents as required by the Employees' State Insurance Corporation regulation and contains 18 fields to record injury details and ensure proper reporting of incidents. 3) Witness information is also collected, including their names, addresses, occupations, and signatures to validate accident reports entered in the log.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    23 views1 page

    Accident Book

    Uploaded by

    Madhu Rajagopalan
    1) This document appears to be an accident report form containing fields to record details of workplace injuries, including the name and address of injured employees, their occupation and insurance details, date and time of injury, cause and nature of injury, and witness information. 2) The form is used to document workplace accidents as required by the Employees' State Insurance Corporation regulation and contains 18 fields to record injury details and ensure proper reporting of incidents. 3) Witness information is also collected, including their names, addresses, occupations, and signatures to validate accident reports entered in the log.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    of 1

    FORM 11

    ACCIDENT BOOK
    EMPLOYEES' STATE INSURANCE CORPORATION
    (Regulation 66)

    Details of Injury
    Name and Address of Injured

    Occupation of the employee


    Shift, department and
    Time of Notice
    Date of Notice

    Insurance No.
    Person
    Sl. No.

    Age
    Sex

    Cause Nature Date Time Place

    1 2 3 4 5 6 7 8 9 10 11 12 13

    What exactly was Name, occupa- Signature and Name, address Remarks, if any
    the injured person tion, address and designation of the and occupation of
    doing at the time signature or the person who makes two witnesses
    of accident thumb impression the entry in the
    of the person(s) Accident Book
    giving notice

    14 15 16 17 18

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