Metalliferous Mines Regulations, 1961 - Directorate General of ...

I have to furnish the following particulars with respect to an occupational disease contracted by a
person employed in the………………………………………… Mine (also state name of mineral produced)
of …………………………. (owner) :
1. PARTICULARS OF THE MINE ETC:
(i) Situation of mine…………………………………
Village……………………………………………
Post office………………………………………..
Police station……………………………………..
Sub-Division (Taluq)…………………………….
District…………………………………………..
State…………………………………………….
(ii)Mineral worked …………………………….
(iii) Name and postal address of owner ………………
2. PARTICULARS OF PERSON AFFECTED :
(I) Name (in Block Capitals) ……………………..
(II) Caste or surname ………………………………
(III) Permanent address –
Village……………………………………………
Post office………………………………………..
Police station……………………………………..
Sub-Divis ion (Taluq)…………………………….
District…………………………………………..
State…………………………………………….
(iv) Sex……………………………………………..
(v) Date of birth (or age)………………………….
(vi) Occupation …………………………………
How long engaged ? ……………………………
(vii) Date of commencement of employment :
(a) in your mine …………………….
(b) In mining ……………………….
(c)
3. PARTICULARS OF DISEASE ETC. :
(i) nature of disease from which the person is suffering (state stage) ……………
(ii) Date of detection of disease …………………………………………………..
(iii) Name, registration number and address of Medical Practitioner suspecting disease………
Signature …………………………
Designation : Owner/Agent/Manager
Date ………………………………..
1[FORM VI
(See regulation 108A)
Name of Mine …………………………….Owner ……………………Manager ………………..
Seam/vein etc. Section/Area etc. …………………………………………………………………….
Inspected by ………………Accompanied by Shri ………………..on ………………………….19.