50TH NATIONAL SAFETY DAY CELEBRATIONS 4TH MARCH 2021

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34th National Safety Day Celebration - 4th March 2005

50^th National Safety Day Celebrations - 4^th March 2021

PROFORMA – V

FOR STATE LEVEL SAFETY AWARDS – BEST SAFETY OFFICER

50TH NATIONAL SAFETY DAY CELEBRATIONS 4TH MARCH 2021

Affix a Passport size Photograph attested by management.

Instructions:

Information shall be furnished for the Three years 2018 - 2020 (01.01.2018 to 31.12.2020)

The Applicant must have worked for at least five years in the field of Occupational Safety & Health and must have worked for at least one year as a designated/notified Safety Officer under section 40B of the Factories Act, 1948 or section 38(2) of the BOCW Act, 1996 and Rules made there under.
Enclose supporting documents wherever required to support information
Separate sheets may be used to furnish additional information if any.
Contact person from the factory for communication (Mandatory)

Name of the Factory Manager		HR Manager
Telephone No./Mobile	Email ID	Telephone No./Mobile	Email ID

1. Name and address of the Factory:

Factory Licence Number:

2. Name of the Occupier & Factory Manager :

3. No. of workers employed in the factory

(A) No. of workers sanctioned as per the license :

No. of workers ordinarily employed: a) Permanent:

b) Contract :

c) Others :

a. Name of the Safety Officer:

Designation:
Qualification B.sc,/ Engineering / Diploma:
Safety Course Details:
No. of years of service in the existing factory as a Safety professional:
No. of years of service in other companies as Safety Officer:
Any other Certification related Safety and Health :

5. Details of Safety, Health & Environment Status:

SHE policy : Yes / No (enclose Copy]

Safety Organization : Yes / No (enclose Copy]

Safety Budget (Year-2020) : Rs.

Safety Audit (Done in the year 2020) : Yes / No (if yes, furnish details)

Safety Officer Appointed : Yes/No (Wherever Applicable)

Accreditations obtained in 2020 : (OSHAS, ISO, etc.)

Other safety awards received in 2020 :

(Note: Please enclose all relevant documents.)

Accident statistics for the calendar year 2020.

a.	No. of Fatal Accidents
b.	No. of reportable accidents (Non-fatal) during the year
c.	No. of dangerous occurrence
d.	Accident frequency and severity rate per 1000 workers
e.	Total no. of man days / man hours worked
f.	No. of man days / man hours lost due to accidents
g.	Longest accident free period
h	Control measures adopted to prevent accidents

7. Accident data for the last three years

	2018	2019	2020
Fatal Accidents
Serious Accidents
Reportable Accidents
Non-reportable Accidents
Near-miss Accidents

Note: 1. Submission of Combined Annual Return-2020 is compulsory

2. Explain your role in accident reporting, investigation and analysis

in your present Factory (1,2.Enclose copies)

8. Safety and Health Status Reports:

Suggestions received / accepted / implemented :
Amount spent on purchase of Safety equipments

in the year 2019-20 and percentage of budget utilized:

9. Details of machine guarding.

Status report.
Amount spent during the year 2019-20.

10. Details of safety awareness programmes:

No. of training programmes conducted :

a) In-house:

b) External:

		2018	2019	2020
1	No of training programmes organized in your present
2	No of training programmes organized with the help of outside expert agencies
3	Permanent workers
4	Workers of all other nature of employment
5	Percentage of workers covered in a year

No. of persons deputed for training outside. Permanent/Contract
Amount spent on SHE training during the year.
Level of awareness on SHE Policy:
No. of Training Programmes conducted through Karnataka State Safety Institute :

(Dept. of Factories and Boilers)

Plant/site safety inspections conducted by you in your present Factory/ Establishment in order to observe the physical conditions of work, work practices and procedures followed by employees.

Year	No. of Plant safety inspections		No. of Remedial measures
Year	Planned	Actual	Suggested	Implemented
2018
2019
2020

Safety Audits organized / conducted by you in your present Factory/ Establishment^.

Year	No. of safety audits	No. of points identified	No. of points corrected
2018
2019
2020

(Attach a latest copy of executive summary of the Safety Audit report & evidence of its implementation.)

13. Mock drills (excluding fire drill) arranged/conducted as per the onsite emergency plan in your present Factory/ Establishment. Explain your role in such mock drill.

Year	No. of mock drill conducted	No. of points observed	No. of revisions made in the Plan
2018
2019
2020

14 .Details of SHE Promotional Activities.

Sl. No	Details	Remarks
a.	Safety committee: i)Central Safety Committee ii) Department wise safety Committee
b.	Workers participation Permanent workers Contract workers
c.	Authority delegated on decision making
d	Chairman of Safety Committee(Designation):

[

Furnish the following details with hard copies:

Sl. No	Compliance	Remarks & Enclosures attached
	No. of Safety and Health Training conducted in 2019 including Toolbox talks, etc., ( List of Trainings conducted, and No of hours covered per person)
	EHS Digitalization - Any initiative to record online Safety and Health Data foreasy access by all in the organization. ( If Yes, Give details.)
	Safety and Health Projects Implemented to minimize the risk.(Best/Better Practice) ( Give the details of Projects highlighting improvement in Safe working Environment- Before & after.)
	Any process developed to ensure compliance to H&S at design stage/ standards. ( Give Details of process)	.
	Details of Serious accidents occurred and actions initiated to improve safe working condition. (Give the trend of accidents for 3 yrs.) (Also furnish Near miss / first aid case & reportable accidents data for 3 years)
	Safety Culture Improvement: -Initiatives taken for conducting Safety Culture survey to improve EHS performance and implementation of BBS program ( If Yes, give the details.)
	Any Safety and Health Recognition for Company received by any other reputed Organizations ( If so the details (Enclose copy of the Certificate)
	Whether the Safety officer was recognized by any other reputed Organizations. ( If so the details (Enclose copy of the Certificate))
	Initiatives implemented to involve employees in safety activities ( Give Details)
	Details of system developed for Handling of H&S Failures, Defects and Anomalies.
	Details of noncompliance notices received from legal authorities on EHS issues
	No. of safety inspections, Risk assessments, Safety committee meetings conducted & Follow up actions
	Explain your contribution in Hazard Identification & Risk Assessment using technique like HAZOP, JSA, QRA, etc. in your present Factory/ Establishment ( Give Details)
	Details of Safety Promotional activities like campaigns competitions, exhibition etc., organized/conducted in your present Factory/ Establishment (Attach copy of celebration report with photo evidence)
	Has your Factory/Establishment won any National/state/local level safety awards during your tenure as safety officer? (Give Details)

Explain in brief why you should be awarded as best safety officer with emphasized performance and your vital role contributed to accomplish the best safe practices in your organization:

Management’s recommendation for the best Safety Officer with reasons:

Signature of the Safety Officer

(Name in block letters)

Occupier/Manager

(Name in block letters)

Signature and seal

Date:

Place:

Please Note:

Completed applications with all the necessary enclosures/documents shall be sent to:

Sri. AJ SatishBabu

Deputy Director of Factories,Division- 4, Bengaluru

Room No.209, 2^nd Floor, ``Karmika Bhavana``Bannerghatta Road, Bengaluru-029.

Mob: 9844076723,

Email id: [email protected],

[email protected], Last date for the submission of application: 10 .02.2021

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