[Prescribed under Rule 96]

Notice of dangerous occurrence which does not result in death or bodily injury
[Vide para 2 of the Schedule under Rule 96]

1. Name and address of the Factory

2. Name of the occupier

3. Name of the Manager

4. Nature of Industry

5. Branch or Department and exact place where the dangerous occurrence took place.

6. Date and hour of occurrence

7. Nature of Dangerous Occurrence
(state exactly what happened)


I certify that, to the best of my knowledge and belief, the above particulars are correct in every respect.


   Signature of the   occupier   or   Manager.

Date of dispatch of report:

Note:- To be completed in legible handwriting or preferably typewriting.

(This space is to be completed by the Inspector of Factories)

Number of accidents or dangerous occurrence:

Industry No.:

Other particulars ( Example fatal, leg injury, arm injury etc.):

Causation No.:

Date of receipt:

Date of investigation:

Result of investigation: