Form XIII

DOCK WORKERS (SAFETY, HEALTH AND WELFARE) REGULATIONS, 1989
(See Regulation 110)

STATEMENT OF ACCIDENTS FOR THE MONTH OF....

Name and address of the employer
Number of reportable accidents under regulation during the month.
Fatal......
Non-fatal........
Number of man-shifts worked during the month (See note 1)
Number of man-days lost on account of absence due to reportable non-fatal accidents in case of persons who returned to work (See note 2)
Number of man-days lost on account of permanent disabilities (See note 3).
Signature.......
Date.......... Designation.......
To
The Inspector,

Item (3): The total number of non-shifts worked is the sum of the number of persons at work on each shift during the month.
Item (4): Number of man-days lost should include days lost due to injury in previous months, that is, if any accident which occurred in previous month is still causing loss of time in the month under review, such loss of time is also to be included in the month under review.
Item (5): Calculation of man-days should be based on the following:
- Man-days lost according to schedule of charges for permanent disabilities as given in Appendix B to IS. 3786-1966. In case of multiple injury, the sum of schedule charges shall not be taken to exceed 6000 man-days.
- If any injury is treated as a lost time injury in one month and subsequently turns out to be a permanent disability, the man-days, charged due to the injury should be subtracted from the schedule charge for the injury when permanent disability becomes known.