Maternity Benefit Act,1961

FORM L: Annual Return for the Year Ending on The 31st December, 20....

[Rule 16]

1 .Name of the mine or circus

2. Situation of the mine of circus

Mauza

District

State

Nearest Railway Station

3. Date of opening of the mine or circus

4. Date of closing, if closed

5. Postal address of the mine or circus

6. Name of employer and postal address of employer

7. Name of managing agent, if any and postal address of managing agent

8. Name of Agent or representative of employer and postal address of representative of employer

9. Name of manager and postal address of manager

10. (a) Name of medical officer, attached to the mine or circus

(b) Qualification of medical officer attached to the mine or circus

(c) Is he resident at the mine or circus ?

(d) If a part-time employee, how often does he pay visits to the mine or circus

11. (a) Is there any hospital at the mine or circus ?

(b) If so, how many beds are provided for women employees ?

(c) Is there a lady doctor ?

(d) If so, what are her qualifications ?

(e) Is there a qualified midwife ?

(f) Has any creche been provided ?

Date ________ Signature of employer