FORM 'J'

See rule 76(I)

Return of Minor Reportable Accidents

Name of the Mine ……………………………………………….

State ……………………….District ……………………………
Owner ……………………………………………………………
Mineral worked ……………………….year …………………..

Classification Date of Duration

Sl. No Initials of
Parts of return of of
Sl Date of Date of Time of By place Brief description of Name of injured from Name of attending
Name of employment body injured enforced Remarks
No. entry accident accident of By cause cause of accident worker register in Injury medical
injured person absence
accident Form B practitioner
to work ( in days)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16