Form 17 – Notice of Accident
PDF · 4 pages · English · Acts & Rules
Form 17 is a statutory accident reporting form used for notifying workplace accidents, injuries, fatalities, and occupational incidents occurring within factories or establishments. The form captures details of the injured employee, accident circumstances, injury nature, witness information, medical treatment, and investigation findings to facilitate statutory reporting, regulatory compliance, and accident analysis.
By Labour Department / Chief Inspector of Factories / Occupational Safety & Health Authority · Published 2026-11-02 · Updated 2026-11-02
From the document
FORM – 17 (Prescribed under rule 106) Notice of Accidents 1. Name of occupier or employer: E.S.I. Employer’s Code No.: 2. Address of works / premises where accident took place- 3. Nature of Industry E.S.I. Insurance No.: 4. Branch or department and exact place where the - accident took place 5. Name and address of the injured person - 6. (a) Sex - (b) Age (last birthday) - (c) Occupation of the injured person - 7. Local E.S.I. Office to which the injured person is - attached 8. Date and hour of accident - 9. (a) hour at which the injured person started work - on the day of accident (b) Whether wages in full or part are payable to - him for the day of the accident 10. Cause or nature of accident - 11. Cause of accident - 12. Cause of accident - (a) If caused by machinery - (i) Give name of machine and the part - causing the accident
(ii) State whether it was moved by mechanical - power at the time (b) State exactly what the injured person was - doing at that time (c) In your opinion, was the injured person at the - time of accident (i) Acting in contravention of provisions - of any law applicable to his employer, or (ii) Acting in contravention of any orders - given by or on behalf …
form 17 · notice of accident · accident report · incident report · injury reporting · workplace accident · occupational injury · industrial accident · factory accident · accident investigation
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