SCHEDULE NO.5
REPORT OF AN ACCIDENT
In accordance with section 92 of the Labour Act. 1997.
1. Name of the factory owner…………………………….
2. Address………………………………………………..
3. Economic activity………………………………………
4. Date of accident……………………………………….
5. Nature of accident……………………………………..
6. Duration of accident…………………………………..
7. If caused by a machine, give name and part causing the injury…..
………………………………………………………..
8. State whether the machine is operated by mechanical power at the time of
accident………………………………………………………..
9. State briefly how the accident occurred………………………….
10. Particulars of injured person or persons:
(a)
(b)
(c)
(d)
(e)
(f)
Name…………………………………………..
Sex…………………………………………….
Age……………………………………………
Address……………………………………….
Pay……………………………………………
Appointment date…………………………….
Date………………… Signature of factory owner……………………..
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