Maternity Benefit Act,1961
FORM M: Employment, Dismissal, Payment of Bonus, Etc., of Women for the year Ending On 31st December, 20......
[Rule 16]
1. Name of the mine or circus
2. Aggregate number of women permanently or temporarily employed during the year
3. Number of women who worked for a period of not less than 2[eighty days] in the twelve months immediately preceding the date of delivery
4. Number of women who gave notice under section 6
5. Number of women who were granted permission to remain absent on receipt of notice of confinement
6. Number of claims for maternity benefit paid
7. Number of claims for maternity benefit rejected
8. Number of cases where pre-natal, confinement and post-natal care was provided by the management free of charge (section 8)
9. Number of claims for medical bonus paid (section 8)
10. Number of claims for medical bonus rejected
11. Number of cases in which leave for miscarriage/ 3[MTP] was granted
12. Number of cases in which leave for miscarriages/ 3[MTP] was applied for but was rejected
3 [12a. Number of cases in which leave for tubectomy operation under section 9A was granted
12b. Number of cases in which leave for tubectomy operation was applied for but was rejected]
13. Number of cases in which additional leave for illness under section 10 was granted.
14. Number of cases in which additional leave for illness under section 10 was granted.
15. Number of women who died
(a) before delivery
(b) after delivery
16. Number of cases in which payment was made to persons other than the woman concerned
17. Number of women discharged or dismissed while working
18. Number of women deprived of maternity benefit and/or medical bonus under proviso to sub-section (2) of section 12
19. Number of cases in which payment was made on the order of the competent authority or Inspector
20. Remarks
N.B.-Full particulars of each case and reasons for the action taken under serials 7, 10, 12, 14, 17 and 18 should be given in Appendix below:-
Date __________ Signature of employer.
