This document contains a declaration form for an occupier of a factory to fill out under the Factories Act, 1948 and Bihar Factories Rule, 1950. The form requests information about the factory name and address, registration details, drawings/maps approved by the Chief Inspector, nature of manufacturing processes and hazards, safety provisions, maximum worker capacity, accidents in the past year, and compliance with various sections of the Act. Checklists are also included to assess compliance with rules regarding cleanliness, ventilation, lighting, machinery safety, fire precautions, and health and safety policies.

1. Declaration under Factories Act, 1948 and Bihar Factories Rule, 1950 to be filled by occupier of factory
Part –1
1. Name of factory- _________________________________________________________
2. Registration number/license number - ________________________________________
3. Drawings/map approved by Chief Inspector of factories – yes No not applicable
If yes, approval number and date of approval -______________________________________
4. the factory is covered under -
(1) Section 85 (2) 2m1 (3) 2m2 (4) others
5. Address for correspondence with factory- ____________________________________________________________________
___________________________________________________________________
Email id -____________________________________________
Mobile /telephone number _______________________________
6. Name of occupier of the factory and address - ________________________________________________________________
_______________________________________________________________
Email id -____________________________________________
Mobile /telephone number _______________________________
7. Name of factory manager of the factory and address- ___________________________________________________________
___________________________________________________________
Email id -____________________________________________
Mobile /telephone number _______________________________

2. 8. the factory is-
MAH unit medium risk industry
Dangerous operations low risk industry
Hazardous process industry
I. In case of MAH unit/hazardous operations whether the Factory has been approved by the site appraisal committee as per section 41-A of Factories Act,1948 (for
factories constituted in or after 28- 06-2012) - yes no
II. In case of dangerous operations (sec 87-FA,1948 and sec-95,BFR-1950) brief description of the nature of process
__________________________________________________________________________________________
___________________________________________________________________________________________
III. In case of hazardous process(section 2cb of Factories Act,1948) a brief description regarding the process and nature of hazard –
_________________________________________________________________________________________________
__________________________________________________________________________________________________
IV. In case of MAH units a brief description regarding the process and nature of hazard-
__________________________________________________________________________________________________
__________________________________________________________________________________________________
V. Whether the industry uses, manufactures and/or stores any hazardous chemicals as specified in the Chapter XI of Bihar factories Rules,1950(Control of Industrial Major
Accident Hazard Rules,1990) yes no
If yes, whether the storage of such chemicals is within the specified limits- yes no
VI. In case of low risk or medium risk industries a brief description of the manufacturing process-
___________________________________________________________________________________________________
___________________________________________________________________________________________________

3. 9. Whether the manufacturing process poses any health hazard to workers as defined in third schedule of factories act, 1948. (sec 89,FA) if yes ,Pleasespecify-
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
10. Total installed capacity of the factory–
A Motor capacity - ________________________in H.P.
B Generation capacity - ________________________ inKWs
C.Transmitting capacity - _________________________ inKWs
D. transforming capacity - _________________________ inKWs
11. Maximum number of workers employed on any day in the factory during the previous 12 months -
Gender Shift A Shift B Shift C General shift
Male
Female
Total
12. any young children employed in the factory premises (sec 67,FA) – yes no
13. annual return being filed by the factory for the previous year under sec110 FA,1948 in prescribed format-Yes No
14. name and address of the concerned factory inspector and certifying surgeon displayed at the main entrance or other conspicuous place in the factory - Yes No
15. name and registration number is displayed at prominent places in the factory – Yes No
16. abstracts of the act is displayed at prominent places in the factory as per the provisions of the act- Yes No

4. 17. the name and quantity of Principal product manufactured and By products produced (if any)
Principal product manufactured
S no Name of principal product Quantity of principal
product
By products produced (if any)
S no Name of by product Quantity of by product

5. 18. any accidents have taken place inside the factory in the past one year - yes no
If yes, type of accident- Fatal Non Fatal
No of workmen injured/deceased or both in the accident-
Injured - Deceased -
A brief description of the nature and cause of accident (sec 88FA, 1948)-
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
______________________________________________________________________________
19. Whether inspection of a premise or factory was prohibited/obstructed/delayed by any person or persons who may be directly or indirectly involved or appears to be involved with
the affairs of the factory (sec 95,FA,1948)
Yes No
If yes please specify
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
20. Whether any prosecution been filed against the factory, if yes please specify
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________

7. Chapter-III
SI
No
Section Checklist Status Remarks
1. section
11
Cleanliness- Whether white washing carried out within 14 months. Yes
No
NA
2. section
12
Disposal of waste and affluent– Whether effective arrangement for the
treatment of wastes and effluents has been provided.
Yes
No
NA
3. section
13
Ventilation and temperature-Whether effective and suitable provision has
been made available for every workroom.
Yes
No
NA
4. section
14
Dust and fume- Whether effective measures have been taken to
prevent its inhalation and accumulation in any workroom.
Yes
No
NA
5. Section.-
16
Overcrowding-Whether at least 350 cubic feet space for every worker and
the internal height of the roof or the ceiling of any room at least 14
feet has been provided.
Yes
No
NA
6. Section.-
17
Lighting-Whether sufficient and suitable lighting natural or artificial or both
has been provided.
Yes
No
NA
7. Section.-
18
Drinking water-(i) Whether effective an arrangement to sufficient
supply of drinking water for all workers employed there has been
provided.
(ii) Whether water supply source has been approved by Health officer.
Yes
No
NA
part 2

8. 8. Section.-
19
Latrines and Urinal- Whether sufficient latrines urinal accommodation for
male and female has been provided.
Yes
No
NA
9. Section.-
20
Spittoons-Whether sufficient number of spittoons in a clean and hygienic
has been made available.
Yes
No
NA

9. chapter IV
SI
No
Section Checklist Status Remarks
1. section
21
Fencing of machinery (section 21,FA-1948)- whether proper and adequate
fencing/safe guards is provided and maintained for safety of workers in case of –
 prime mover and flywheel
 Headrace and tailrace of every waterturbine
 Stockbar projecting beyond headstoke of a lathe
 Electric generator, motor or rotary converter
 Every part of transmission machinery
 Every dangerous part of any machinery
Yes
No
NA
2. section
22
Work on or near machinery in motion(sec 22,FA-1948)- In case of
operation, lubrication or inspection of machinery in motion Whether the
worker(adult male workers only) suitably trained to do the job and is wearing tight
clothes provided by the occupier.
Yes
No
NA
3 section
22
Whether the name of the worker been recorded in a register and whether the
worker been furnished with a certificate of his appointment for doing such work
Yes
No
NA
4 Section
22
Provisions relating to handling of belt and moving pulley been adhered to Yes
No
NA
5 Section
22
All parts of moving machinery including nuts, bolts ,studs etc. have been securely f
enced
Yes
No
NA
6 section
22
Whether any women or young person(without proper training and supervision) is
employed near such machines.
Yes
No
NA
7 section
24
Striking gear and devices for cutting off power (sec-24,FA-1948)-
whether proper and effective appliances and devices are maintained in case of
moving belts and other running machinery as required as per the provisions of
theact.
Yes
No
NA

10. 
8 section
25
Self acting machines (sec -25,FA-1948)- whether any traversing part of
a self acting machine or any material carried thereon is allowed to run so that
any worker is liable to pass within a distance of 45 cms from any fixed
structure which is not a part of the machine.
Yes
No
NA
9 section
26
Casing of new machinery (sec 26, FA-1948)
in case of machinery driven by power whether all set screws,bolts, keys, spur
worm etc is effectively guarded and /or completely encased as per the
provisions of the act.
Yes
No
NA
10 section
27
Prohibition of employment of children or women
near cotton openers (sec 27,FA1948) unless otherwise exempted as per the
provision of the act whether any children or women has been appointed in any
part of the factory for pressingcotton
Yes
No
NA
11 section
27
Hoists and lifts (sec 27,FA-1948)-
whether for every hoist and lift used in a factory the strength and design of
construction material is of adequate strength and properly maintained and
approved by competent authority every six months with records maintained in a
register
Yes
No
NA
12 Section
27
every lift or hoist is fitted with enclosures /cages etc. to avoid persons or things
being trapped between the moving part and stationary structure of the hoist or lift
Yes
No
NA
13 Section
27
Safe working load is prominently displayed and interlocking are provided Yes
No
NA
14 section
27
Any other safety requirement or provisions has been adhered to in compliance
with the use of lifts and hoists as directed by the CIF or the state government.
Yes
No
NA
15 section
29
lifting machines chains ropes and lifting tackles (sec 29,FA-1948) –
whetherfor such equipments material of construction is free from defects and of
good strength and properly maintained
Yes
No
NA

11. 16 section
29
Examined by a competent authority every 12 months and a register being maintain
ed for such examinations conducted
Yes
No
NA
17 section
29
Provisions for safe working load is adhered to Yes
No
NA
18 section
29
Effective measures are taken to avoid any person being struck by a travelling
crane
Yes
No
NA
19 section
29
Any other safety provisions as laid down by state government
has been adhered to
Yes
No
NA
20 section
30
Revolving machinery (sec 30)
in case of revolving machinery whether all the necessary details regarding
the speed of moving parts-shaft, spindle, wheel etc is within the safe
working limit and prominently displayed for safety of workers and never
exceeded beyond safe limit
Yes
No
NA
21 section
31
Pressure plants (sec 31) –
whether effective measures been adopted to ensure that the safe working
pressure of such plants is not exceeded
Yes
No
NA
22 section
31
whether testing or examination of the pressure vessel or any part thereof has
been done by competent authority.
Yes
No
NA
23 Section
32
Floors ,stairs and means of access(sec32)- whether all floors, stairs steps
or other means of access in a factory is of sound construction and properly
maintend and provided with hand rails, easily accessible and provided with
reasonable fencing or safety norms so as to prevent falling of any worker from
height
Yes
No
NA
24 section
33
Pits, sumps, opening in floors etc.(sec 33) - whether provisions relating to
fencing or covering securely to avoid danger .
Yes
No
NA

12. 25 Section
34
Excessive weights (sec 34)whether maximum load that can be carried ,
lifted or moved by workers is within the prescribed limits
Yes
No
NA
26 Section
35
Protection of eyes(sec35)- whether suitable screens ,goggles etc are
provided if any danger persists relating to exposure of eyes to excessive
light or due to fragments or particles thrown off in the course of
manufacturing process.
Yes
No
NA
27 Section
36
Precautions against dangerous fumes, gases etc.(sec 36) - whether there
are suitable provisions for adequate size of manhole or other effective means of
egress if a person is allowed to enter into a confined space where any
possibility of gas, fume,vapors or dust accumulation persists which may be
dangerous.
Yes
No
NA
28 Section
36
Whether such accumulated dust, gas, fumes etc have been removed from the
confined space before aperson enters it and a certificate in writing has been given
by competent person to ensure safety.
Yes
No
NA
29 section
36
Whether the person entering the confined space is wearing suitable breathing
apparatus and a belt attached to a rope held by another person outside the confine
space.
Yes
No
NA
30 section
36 A
Precutions regarding use of portable electric light(sec 36A)- Whether the
voltage of portable electric light is less than 24 volts and provided with adequate
safety devices if used inside a confined space.
Yes
No
NA
31 section
36 A
Whether the portable is made of flame proof construction when used inside a
confined space where any inflammable gas, fume or dust is likely to be present.
Yes
No
NA
32 Section
37
Explosive or inflammable dust ,gas etc.(37) - in case of factories if any dust,
gas, fume or vapor is produced which is likely to ignite or explode-
whether effective measures have been taken to avoid such explosion by-
effective enclosure of plant and machinery; removal or prevention of accumulation
of such dust or gas and exclusion of all possible sources of ignition
Yes
No
NA

13. 33 Section
37
Effective appliances like- vents, baffles chokes etc are provided in case of
machinery which cannot withstand pressure due to an explosion
Yes
No
NA
34 Section
37
Pressure vessels containing inflammable or explosive material is
in compliance with the provisions of the act
Yes
No
NA
35 Section
37
Whether safety precautions regarding welding, soldering, cutting etc of such vess
els have been followed.
Yes
No
NA
36 Section
38
Precaution in case of fire(sec38) –
whether effective measures have been adopted to prevent outbreak of
fire and its spreading internally and externally
Yes
No
NA
37 Section
38
Provisions for safe means of escape for all persons in case of fire Yes
No
NA
38 Section
38
Adequate number of equipments and facilities for extinguishing fire Yes
No
NA
39 Section
38
Whether workers have been trained and are familiar with escape routes in case
of fire
Yes
No
NA
40 Section
38
Whether any additional measures been directed by CIF or state Government and
complied with
Yes
No
NA
41 Section
39
Defective parts or test of stability(sec39)-
Whether any part of building or machinery or plant is considered defective or
dangerous to human life or safety
Yes
No
NA

14. 42 Section
40-1
Safety of building or machinery (sec 40-1) –
Whether any building, part of building ,machinery or plant etc inside a
factory is dangerous to human life or safety
Yes
No
NA
43 Section
40-1
Whether any part of the factory building, machines has been prohibited from use
until reparing is done
Yes
No
NA
44 section
40 A
Maintenance of building(sec 40A)
whether any building or part of building appears to be in a state of
disrepair which may be detrimental to health and welfare of workers
Yes
No
NA
45 section
40 B
Safety officers (sec 40-B) –
whether safety officers are employed in adequate numbers and with required
qualifications and conditions of service (for 1000 or more workers)
Yes
No
NA

15. Chapter-IVA
SI
No
Section Checklist Status Remarks
1. section
41B
Whether information regarding dangers, health hazards and the
measures to overcome such hazards arising from the exposure or
handling of the materials or substances in the manufacture,
transportation, storage and other processes, been provided to the
workers employed in the factory, the chief inspector
Yes
No
NA
2. section
41B
Whether detailed health and safety policy of workers has been
constituted prior to registering a factory and the same has been
approved by CIF
Yes
No
NA
3. section
41B
Whether any changes recommended by the CIF has been complied with
in the health and safety policy of workers
Yes
No
NA
4. section
41B
Whether on site emergency plan and detailed disaster control
measures been framed and approved by the CIF.
Yes
No
NA
5. Section.
-41B
Whether the workers employed and the general public living in the
vincity of the factory aware of the safety measures required to be
taken in the event of an accident taking place in the factory.
Yes
No
NA
6. Section.
41C
Whether up to date health records, medical records maintained for
workers and is accessible to workers prior to employment,during
employment and after one ceases to be employed in the factory every
12 months
Yes
No
NA

16. 7 Section.
41C
Whether any person is appointed as supervisor and posses required
qualification and experience in handling hazardous substances
Yes
No
NA
8 Section.
41D
Whether any advisory inquiry committee been appointed by the central
government earlier to inquire health and safety standards of the factory
Yes
No
NA
9 Section.
41F
Whether the permissible limit of exposure within the prescribed limits
as per second schedule of the act for chemicals and toxic wastes.
Yes
No
NA
10 Section.
41G
Whether safety committee been formed in such factories with
proportionate representation of number of members from
representatives of workers and management
Yes
No
NA
11 Section.
41G
Whether periodic meetings of safety committee held and
proceedings of meeting duly complied with
Yes
No
NA
12 Section.
41H
Have there been any dangerous occurrences reported by workers
and whether the inspector been informed regarding such
occurrences
Yes
No
NA
13 Section.
41H
Whether any immediate remedial action required for the reported
incidence and report was sent to factory Inspector
Yes
No
NA

17. Chapter-V
SI
No
Section Checklist Status Remarks
1. section
42
Washing facility section 42 male and female are separate facilities Yes
No
NA
2. section
42
Is water supply source approved by Health officer Yes
No
NA
3. section
43
Facilities for storing and drying of clothing’s provided to workers Yes
No
NA
4. section
45
First aid box with adequate equipment present Yes
No
NA
5. Section.
45
Person trained in First-aid-treatment present in every shift Yes
No
NA
6. Section.
45
Is ambulance room available Yes
No
NA

18. 7 Section.
45
Medical officers/Nurses have requisite qualification Yes
No
NA
8 Section.
45
Is ambulance van available
Yes
No
NA
9 Section.
46
Is canteen available Yes
No
NA
10 Section.
46
Is canteen managing committee functional Yes
No
NA
11 Section.
47
Is shelters/rest room & lunch room available Yes
No
NA
12 Section.
48
Is crèches available Yes
No
NA
13 Section.
49
Is there welfare officer employed Yes
No
NA

19. Chapter – VI
Sl.
No.
Section Checklist Status Remarks
1 Section 51
Weekly hours- Whether any adult worker is allowed/required
to work for more than 48 hours in a week.
Yes
No
NA
2 Section 52
Weekly holidays - Whether any adult worker is
allowed/required to work with a weekly holiday as per the
section 52.
Yes
No
NA
3 Section 53
Compensatory holidays - Whether any adult worker is
allowed/required to work with a Compensatory holiday as per
the section 53.
Yes
No
NA
4 Section 54
Daily hours - Whether any adult worker is allowed/required to
work for more than nine hours in any day.
Yes
No
NA
5 Section 55
Intervals for rest - Whether any adult worker is allowed to
work for more than five hours before he has had an interval for
rest of at half an hour.
Yes
No
NA
6 Section 56
Spread over - Whether any adult worker is allowed to spread
over more than ten and a half hours in any day.
Yes
No
NA
7 Section 57
Night shifts – In case of a worker works on a shift which
extends beyond midnight, a holiday as well as working hour
count should be provided as per the section 57.
Yes
No
NA
8 Section 58
Prohibition of overlapping shifts – Whether work is carried
on by means of a system of shifts so arranged that more than
one relay of workers is engaged in work of the same kind at
the same time.
Yes
No
NA

20. 9 Section 59
Extra wages for overtime – In case of a worker works for
more than nine hours in any day or for more than forty-eight
hours in any week, extra wages for overtime should be
provided as per the section 59.
Yes
No
NA
10 Section 60
Restriction on double employment - Whether any adult
worker is allowed/required to work on any day on which he has
already been working in any other factory, save in such
circumstances as may be prescribed.
Yes
No
NA
11 Section 61
Notice of periods of work for adults – Whether a notice of
periods of work for adults in Form no. 11 is displayed and
correctly maintained as per the section 61 of Factories Act,
1948 and Rule 79 of Bihar Factories Rules, 1950.
Yes
No
NA
12 Section 62
Register of adult workers - Whether a register of adult
workers in Form no. 12 is maintained as per the section 61 of
Factories Act, 1948 and Rule 80 of Bihar Factories Rules, 1950.
Yes
No
NA
13 Section 63
Hours of work to correspond with notice under section
61 and register under section 62 - Whether any adult
worker is allowed/required to work in factory otherwise than in
accordance with the notice of periods of work for adults
displayed in the factory and the entries made before hand
against his name in the register of adult workers of the factory.
Yes
No
NA
14 Section 66
Further restrictions on employment of women – Whether
provisions of the further restrictions on employment of women
as per the section 66 is provided to women.
Yes
No
NA

21. Chapter-VIII
SI
No
Section Checklist Status Remarks
1. section
79
Is annual leave with wages given to worker as per provisions of the act Yes
No
NA
2. section
83
Is leave with wages register maintained in prescribed format Yes
No
NA
3. section
83
Is leave Book maintained in prescribed format Yes
No
NA
4. section
90, Rule
(BFR,
1950)
Has Notice to Inspector produced before involuntary unemployment of worker
from factory.
Yes
No
NA
5. Section.-
93Rule
(BFR,
1950)
Has nomination in Form no-25 been submitted by worker for payment of
wages if the worker dies?
Yes
No
NA

22. Chapter-IX
SI
No
Section Checklist Status Remarks
1. section
87A
Whether it appears that the conditions in a factory or part thereof may cause
serious hazard injury or death to persons employed therein.
Yes
No
NA
2. section
88
Whether accidents occurring in a factory been reported within the stipulated
time to concern authority.
Yes
No
NA
3. section
88A
Whether any dangerous occurrences been duly notified to the concerned
authority..
Yes
No
NA
4. section
91
Whether any sample/ samples is required to be taken as per the provisions of
the act.
Yes
No
NA
5. Section.-
91A
Whether any safety and occupational health surveys been undertaken as per
the provisions act
Yes
No
NA