FORM ‘L’
(See Rule 16)
Annual return for the year ending on the 31st. December, 19___.
1. Name of the establishment.
2. Situation of the establishment--
Mauza
District
State
Nearest Railway Station.
3. Date of opening of establishment
4. Date of closing, if closed.
5. Postal address of establishment.
6. Name of employer.
7. Name of the managing agent, if any Postal Address of managing agent.
8. Name of agent or representative of employer
Postal address of representative employer
9. Name of Manager
Postal address of Manager.
10. (a) Name of medical officer attached to the establishment
(b) Qualification of medical officer attached to the establishment.
(c) Is he resident at the establishment?
(d) If a part-time employee, how often does he pay visits to the establishment?
11. (a) Is there any hospital at the establishment?
(b) If so, how many beds are provided for woman employees?
(c) Is there a lady doctor?
(d) If yes, what are her qualifications?
(e) Is there a qualified midwife?
(f) Has any crèche been provided?
Signature of employer
Dated_________________
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