34th National Safety Day Celebration - 4th March 2005



51st National Safety Day Celebration - 4th March 2022

PROFORMA – IV

FOR STATE LEVEL SAFETY AWARDS – BEST WORKER

Affix a Passport size Photograph attested by management.

Instructions:

Information shall be furnished for the calendar year 2021 (01.01.2021 to 31.12.2021)

1. Only one application can be made from a factory.

2. Only workmen and operators are eligible to apply.

3. The winners of the past two years are not eligible to participate.

4. Supervisors, Engineers, Managers & Other Management Staff are not eligible to apply.

5. Enclose supporting documents wherever required in support of statistics.

6. Separate sheets may be used to furnish additional information if any.

7. Contact person from the factory for communication (Mandatory)

|Name of the Manager |HR Manager |

|Telephone No./Mobile |Email ID |Telephone No./Mobile |Email ID |

| | | | |

1. Name and address of the Factory and License No.:

(Attach latest copy of the factory licence)

2 (A). Brief description of the nature of manufacturing activity

carried on in the factory:

(B). Classification of Industry / Category (Please ( or ()

(Category is based on the total number of wokers to which licence has been given)

|Up to 100 workers (Small Industries ) | |

|101 to 500 workers (Medium Industries ) | |

|501 to 1000 workers (Large Industries ) | |

|Above 1000 workers (Mega Industries) | |

|Oil Industry (LPG/Petroleum Products (POL) Storage, Bottling / Depot, | |

|Terminals & Refinery) | |

3. Name of the worker :

4. Designation :

5. Section/Department :

6. Years of service in the factory :

7. Age of the worker :

8. Qualification :

(a) General :

(b) Technical :

9. (a) Whether member of Safety Committee : Yes / No

(b) Whether trained in First Aid Treatment : Yes / No

(c) Whether trained in Fire Fighting : Yes / No

(d)Whether Member of Emergency Management Team : Yes/No

10. Training acquired in the field of safety:

11. Suggestions given to improve safety standards or to avoid accidents in the calendar year-2021:

12. Outstanding performance in the field of safety in the calendar year-2021:

13. Whether averted any accident during the tenure of his service:

14. Employer’s recommendation for the best worker with reasons:

15. Whether the worker has got safety award by any other reputed

Organizations. If so the details (Enclose copy of the Certificate) :

16. Whether the worker is the recipient of state level awards from the Dept. of

Factories, Boilers, Industrial Safety & Health? If so give details.

Signature and seal of the Occupier/Manager Signature of the Worker

(Name in block letters) (Name in block letters)

Date:

Place:

Please Note:

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

Sri. H.S.Narendrababu,

Joint Director of Factories,

Region-2, Bengaluru.

Room No.102, 1st Floor, ``Kalyana Suraksha Bhavana``,

Bannerghatta Road, Bengaluru-560 029.

Mob: 9663374033

Email id: hsnarendrababu@

Last date for the submission of application: 10.02.2022.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download