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Form 4a

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FORM 4 - A

Notice of Accident/Dangerous Occurrence

(See Regulation 8)

From

(Owner, agent or manager)

Name

Postal address

District

State

PIN

Mobile Number

Telephone Number (Landline)

Fax number

Email ID

To:

1. The Chief Inspector of Mines/Director General of Mines Safety, Dhanbad-826001


2. The Regional Inspector of Mines/Director of Mines Safety ………Region / Dy. Director in Charge of Sub-
Region.
3. The District Magistrate / District Collector.
4. The Electrical Inspector of Mines/Director/Dy. Director of Mines Safety (Electrical) (Electrical accidents
only)
5. Competent Authority (for payment of compensation)- In case of accident mentioned in Sub-
Regulation 1 (a) of Regulation 8.

Sir,

I have to furnish the following particulars of fatal/serious accident/ dangerous occurrence(*) which
occurred at

1. Name of Mine
2. Name of Owner
3. Mine Code (nnnnnn):
4. Labour Identification Number (LIN)
5. Date of accident (DD/MM/YYYY)
6. Time of Accident (hhmm)
7. Particulars of the mine:
7.1 Mineral
7.2 Village/area/road

7.3 Post Office

7.4 Sub-Division (Taluq)/Tehsil

7.5 District

7.6 State

7.7 Pin Code

7.8 Police Station

7.9 Railway station(nearest)

8. Postal address of
owner 8.1
Village/area/road

8.2 Post Office

8.3 Sub-Division (Taluq)/Tehsil

8.4 District

8.5 State

8.6 PIN

8.7 Police station

8.8 Railway station(nearest)

8.9 Email Id.

8.10 Telephone number (land line)

8.11 Fax number

8.12 Mobile number(s)


9. Particulars of the Accident
9.1 Number/Name of shift
9.2 Cause code (nnnn)

9.3 Place code (n)

9.4 Workings code (n)

9.5 No. of persons killed

9.6 No. of persons seriously injured

9.7 Location of accident

9.8 Pit/Incline No.

9.9 District/Panel/bench/outside working district

9.10 Seam

9.11 Level, dip number

9.12 Distance from the face (in metre)

9.13 Details not covered above(if within district)


10. Particulars of person(s) involved:

Sl No. Name of Desig- Desig.Code If contractor Sex Age Hours Nature of

victim nation (nn) worker (Y/N) (M/F) (Years) at work injury

(nn) (hhmm)

Killed

1.

2.

Seriousl
y injured :

1.

2.

11. Brief description of the cause of accident/occurrence (*)


12. Immediate last accident: Fatal/Serious (*)
13. Date of immediate last accident (DD/MM/YYYY)

Particulars in respect of every person killed or injured in Form IV-B are enclosed / shall be forwarded within a
week.

Yours faithfully,

Signature:

Name in block letters:

Designation

(Owner/agent/manager)

Date:

Place:

*delete whichever is not applicable.

CODES TO BE USED IN FORM 4-A


CAUSE CODE

CODE Details of cause

0111 Fall of Roof

0112 Fall of Sides

0199 Other Falls of Ground

0221 Over winding of Cages, Skips etc.

0299 Other accidents / Dangerous occurrences due to winding

0332 Rope Haulage

0334 Conveyors

0335 Dumpers

0339 Other Wheeled Trackless

0399 Other non-winding Machinery

0448 HEMM other than Dumpers

0499 Other Machinery

0500 Explosives

0600 Electricity

0775 Spontaneous Heating

0799 Other accidents / dangerous occurrence due to dust / gas / fires

0881 Fall of Persons

0883 Fall of Objects

0889 Others (falls other than ground movement)

0999 Other than above

PLACE CODE

CODE DESCRIPTION OF PLACE

1 Below ground

2 Opencast

3 Above ground

WORKINGS CODE

CODE DETAILS OF WORKING

1 Development

2 Longwall

3 Depillaring
4 Coal bench

5 O/B Bench

6 Waste Dump

9 Others

DESIGNATION CODE
ACTUAL
CODE DESIGNATION
20 Management

30 Subordinate Supervisory Officials

41 Loaders

42 Support Personal

43 Dresser

44 Shotfirer

Other B/G Face


49 Worker

50 Other B/G Worker

59 Trammer

60 Fitter

71 Dumper Operator

72 Truck etc. Operator

79 Other Operator

99 Any Other

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