FORM 4 - C

Particulars of injured person(s) returning to duty

(to be given in respect of every person within 15 days of his return to duty)

(See Regulation 8)

From

(Owner, agent or manager)

Name

Postal address

District

State

PIN

Mobile Number

Telephone Number (Landline)

Fax number

Email ID

To:

1. The Chief Inspector of Mines/Director General of Mines Safety, Dhanbad-826001

2. The Regional Inspector of Mines/Director of Mines Safety ………Region / Dy. Director in Charge of Sub-Region.

Sir,

I have to furnish the following particulars of injured person(s) returning to duty

1. Name of Mine
2. Name of Owner

3. Mine code (nnnnnn):

4. Labour Identification Number (LIN)

5. Date of accident (DD/MM/YYY)

6. Time of Accindent (hhmm)

Sl. Name(s) of Date of return to Whether Permanent Ex-gratia Statutory Benefits to

No. injured duty returned Disablement payment Compensation dependents or

worker's (dd/mm/yyyy) to regular Part(s) of body made paid (Rs.) other benefits

or other Loss Gone (Rs.)

job out of

use

1.

2.

3.

4.
 Signature:

Date: Name in Block letters:

Place: Designation: Owner / Agent/Manager