Rules and Regulations of India

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Form 15 – EMPLOYEES’ STATE INSURANCE (GENERAL) REGULATIONS,1950

FORM 15: Accident Book

[Regulation 66]

Serial No _______________

Date of notice ______________

Time of notice __________________

Name and address of the injured person __________

Sex ____________

Age ____________

Insurance No _______________________

Shift, department and occupation of employee ________________

Injury _______________________

Date _________________________

Time ___________________________

Place ___________________________

Cause of injury ___________________

Nature of injury ___________________

What exactly was the injured person doing at the time of injury ______

Name, occupation, address and signature or the thumb impression of the persons  giving notice ___________________

Signature and designation of the person who makes the entry _______

Name, address and occupation of two  witnesses

_______________________________________________________________________________________________

Remarks, if any ___________________

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