Department of Labour and Employment FORM D [See Section 4(i) Proviso (b) (i) and (ii)] Monthly Register showing Welfare Amenities to be maintained by small establishments and very small establishments Name and Address of the Address of the For the month of Employer Establishment: Local / Permanent SL. No. Name of the Employee Sex Designation Weekly day of rest Dates of holidays for festivals or similar other occasions 1 2 3 4 5 6 Number of Casual leave availed by the employee Quantum of annual leave with wages Whether Welfare Amenities provided for Due Availed Rest Room Drinking Water First Aid 7 8 9 10 11 12 Whether Scheduled Caste / Scheduled Tribe, Handicapped, or any other particular category Signature of the employee or his agent Remarks of the Inspecting Officer Signature of Inspector with date 13 14 15 16 Note: To be completed within seven days of the expiry of each calendar month. Date: Place: Signature of the Employer with full name in Capitals.
