FORM A
(See rule 3)
MUSTER-ROLL
Name of [organisation]………………………………………………………………….. 1. Serial Number…………………………………………………………………………..
2. Name of woman and her father’s (or, if married, husband’s) name………………….. ………………………………………………………………………………………….
3. Date of appointment…………………………………………………………………...
4. Nature of work…………………………………………………………………………
5. Dates with month and year in which she is employed, laid off and not employed.
Month No. of No. of No. of
days days laid days not Remarks
………………………………………………………………………………………………
6. Date on which the woman gives notice under section 6……………………………...
7. Date of discharge/dismissal, if any……………………………………………………
8. Date of production of proof of pregnancy under section 6……………………………
9. Date of birth of child…………………………………………………………………..
10. Date of production of proof of delivery/miscarriage/[Medical Termination of pregnancy/ tubectomy operation/death.]…………………………………………….. …………………………………………………………………………………………. 11. Date of production of proof of illness referred to in section 10………………………
12. Date with the amount of maternity benefit paid in advance of expected delivery….. ………………………………………………………………………………………….
13. Date with the amount of subsequent payment of maternity benefit………………… ………………………………………………………………………………………….
14. Date with the amount of bonus, if paid, under section 8……………………………. ………………………………………………………………………………………….
15. Date with the amount of wages paid on account of leave under section 9…………. …………………………………………………………………………………………
[15A. Date with the amount of wages paid on account of leave under section 9A.]…. …………………………………………………………………………………………. 16. Date with the amount of wages paid on account of leave under section 10 and period of leave granted……………………………………………………………….. ………………………………………………………………………………………….
17. Name of the person nominated by the woman under section 6……………………… ………………………………………………………………………………………….
18. If the woman dies, the date of her death, the name of the person to whom maternity benefit and/or other amount was paid, the amount thereof, and the date of payment……………………………………………………………………………..
19. If the woman dies and the child survives, the name of the person to whom the amount of maternity benefit was paid on behalf of the child and the period for which it was paid……………………………………………………………………… ………………………………………………………………………………………….
20. Signature of the employer of [the organisation] authenticating the entries in the muster-roll……………………………………………………………………………... 21. Remarks column for the use of the Inspector.
FORM B
[See rule 4(1)]
This is to certify that I examined..................................wife/daughter of……..... …………………………. a woman employee in....................................................... ……………………………………………………………………………………………… (name of [organisation]) on............................................................................... (date) and found/cannot discover that she is pregnant and is expected to be delivered of a child within (month and/days) from the above mentioned date/has undergone miscarriage/ [Medical termination of pregnancy or tubectomy operation]/has been delivered of a child on…………….....(date) or is suffering from ……………......(date) from illness arising out of pregnancy/delivery/premature birth of a child or miscarriage/[Medical termination of pregnancy or tubectomy operation].
Signature, qualifications and designation of
Medical Officer/Medical Practitioner.
Date...........................
Definitions of “child” and “miscarriage” as in the Maternity Benefit Act, 1961.—
1. “Child” includes a still-born child.
2. “Miscarriage” means expulsion of the contents of a pregnant uterus at any period prior to or during the twenty-sixth week of pregnancy but does not include any miscarriage, the causing of which is punishable under the Indian Penal Code.
FORM C
[See rule 4(4)]
This is to certify that Smt............................................................... wife/daughter of…………………………………………………………....employed in …………………………………………………………………………………………...... (name of [organisation]) expired on .........................................before/ during/after confinement. The child died on……………..../survives her. Signature, qualifications and designation of
Medical Officer/Medical Practitioner
Date...............................
FORM D
[See rule 4(5)]
This is to certify that I examined.................................................... wife/daughter of................................................................................................. a woman employed in .......................................................................................... (name of [organisation]) and found that she has been delivered of a child/has undergone miscarriage on…………………………….....(date). Signature of registered midwife.
Date..... ...................
Definitions of “child” and “miscarriage” as in the Maternity Benefit Act, 1961—
1. “Child” includes a still-born child.
2. “Miscarriage” means expulsion of the contents of a pregnant uterus at any period prior to or during the twenty-sixth week of pregnancy but does not include any miscarriage, the causing of which is punishable under the Indian Penal Code.
FORM E
[See rule 5(1)]
NOTICE UNDER SECTION 6 OF THE MATERNITY BENEFIT ACT, 1961
To
……………………………….....(name of [organisation]) 1 …………………………………………………………..... (name of woman) wife/daughter of ............................................... employed as........................... at……………………………..... (name of [organisation]), hereby give notice that I expect to be confined within six weeks next following from the date of this notice/have given birth to a child on ....................................................(date) and shall be absent from work from .......................................................(date). I shall not work in any establishment during the period for which I receive maternity benefit. 2. For the purpose of section 7, I hereby nominate………………………………...... (here enter name and address of the nominee) to receive maternity benefit and/or any other amount due to me under the Act in case of my death.
Signature of an Attester in case
the woman is not able to sign
and affix thumb impression. Signature or thumb impression of woman
Date................................
FORM F
[See rule 5(3)]
FORM OF RECEIPT OF MATERNITY BENEFIT
To
…………………....... (name of [organisation]) I, …………………………………..... the undersigned, a woman employee/the nominee of .......................................................woman employee/legal representative of.......................................... woman employee deceased in .............................................(name of [organisation]) at………………………... in………………………………………... district received maternity benefit and/or other amount due under the Maternity Benefit Act, 1961, from the employer of [organisation] referred to above, as detailed below:— Rs........................ being the first instalment of maternity benefit paid on..................
Rs....................... being the second instalment of maternity benefit after delivery paid on.........................
Rs…………………………........ being the medical bonus under section 8 of the Act paid on.......................................
Rs……………………………………....... being the wages for the leave period from ………………............ to…………...... mentioned under [section 9,9Aor 10]. *My/Her confinement/miscarriage [Medical termination of pregnancy or tubectomy operation] took place on.....or I/she fell ill because of pregnancy, delivery, premature birth of a child or miscarriage [Medical termination of pregnancy or tubectomy operation] on………………………...... In consequence I...................................... her nominee/legal representative have received the aforesaid amounts prescribed in [sections 5, 8, 9, 9A and 10] of the Maternity Benefit Act, 1961.
Signature or thumb impression of.....
* Woman employee or her nominee or legal representative
Signature of an Attester in case the woman is
not able to sign and affixes thumb impression
Date.....
* Strike out unnecessary portion.
FORM G
[See rule 9]
To
The Competent Authority
(Appointed under the Maternity Benefit Act, 1961).
………………………......(Address)
Sir,
I………………………………………........ the undersigned, woman employee of............................ (name and full address [organisation]) have been wrongly deprived by the employer of maternity benefit or medical bonus or both (strike out unnecessary portion) for the reasons attached hereto, prefer this appeal under sub-section (2) of section 12 and request that the said employer be ordered to pay the above mentioned amount to me. A copy of the order of the employer in this behalf is enclosed. Date .......................................... Signature or thumb impression of the woman
Signature of an Attester in case the woman is
not able to sign and affixes thumb impression.
Full address of the nominee/legal representative
FORM H
[See rule 10]
To
The Inspector,
(Under the Maternity Benefit Act, 1961)
Sir,
I……………………………………………..... (name of woman) employed in ………………………………....... (name and full address of [organisation]) having fulfilled the conditions laid down in the Maternity Benefit Act, 1961 and the Rules thereunder, am entitled to Rs...... being maternity benefit and/or Rs..... being the medical bonus and/or Rs...... being wages for leave due under [section 9 or 9A] 10 but the same has been improperly withheld by the employer. He may, therefore, be directed to pay the amount to me.
Date…………………………… Signature or thumb impression of the woman
Signature of an Attester in case the woman is unable to sign and affixes thumb impression.
Date……………………………........ Full address of the woman.
FORM I
[See rule 10]
To
The Inspector
(Under the Maternity Benefit Act, 1961)
I……………………………………....(name), a person nominated under section 6 by or a legal representative of........................................ (name of woman) employed in................................................. (name and full address of [organisation]) have to complain that the said woman having fulfilled the conditions laid down in the Maternity Benefit Act, 1961 and the Rules thereunder is entitled to Rs………………..... being maternity benefit and/or Rs..... being the medical bonus and/or Rs………………………..... being wages for leave due under [section 9 or 9A] or 10 but the same has been improperly withheld by the employer. He may, therefore, be directed to pay the amount to me. Date …………………...... Signature or thumb impression of the nominee/legal representative
Signature of an Attester in case the nominee/legal
representative is unable to sign and affixes thumb impression.
Date …………………………..... Full address of the nominee/legal representative.
FORM J
[See rule 11]
To
Sir,
Shri………………………...... Inspector, having directed under sub-section (2) of section 17 to pay the maternity benefit or other amount being………………...... (nature of amount) to which...................................... (name of woman) is said to be entitled, I prefer this appeal under sub-section (3) of section 17. In view of the facts mentioned in the memorandum attached hereto and other documents filed herewith it is submitted that the woman is not entitled to the maternity benefit or the said amount and hence the decision of the Inspector in this behalf, copy of which is enclosed, may be set aside.
Signature of aggrieved person.
Full address.......................
Date....................
FORM K
[See rule 15]
(Abstract of the Maternity Benefit Act, 1961, and the rules made thereunder).
1. No employer shall knowingly employ a woman during the six weeks immediately following the day of her delivery of miscarriage/[Medical termination of pregnancy] and no woman shall work in any establishment during the said period. 2. No pregnant woman shall, on a request being made by her in this behalf, be required by her employer to do during the period of one month immediately preceding the period of six weeks before the date of her expected delivery and also for any period during this period of six weeks for which she does not avail of leave of absence, any work which is of an arduous nature or which involves long hours of standing, or which in way is likely to interfere with her pregnancy or the normal development of the foetus, or is likely to cause her miscarriage or otherwise to adversely affect her health.
3. [(1) Subject to the provisions of the Act, every woman who has actually worked in an establishment of the employer from whom she claims maternity benefit for a period of not less than eighty days, including the days during which she was laid off, shall be entitled to, and her employer shall be liable for, the payment of maternity benefit at the rate of her average daily wages, or the minimum rate of wage fixed or revised under the Minimum Wages Act, 1948, or ten rupees a day, whichever is highest, for the period of her actual absence not exceeding six weeks immediately preceding the day of delivery and the remaining period immediately following that day: Provided that the qualifying period of eighty days aforesaid shall not apply to a woman who has immigrated into the State of Assam and was pregnant at the time of the immigration:
Provided further that where a woman dies during the period for which maternity benefit is pay able to her, the benefit shall be payable only for the days upto and including the day of her death. However, where the woman having been delivered of a child, dies during her delivery or during the remaining period of maternity benefit leaving behind in either case the child, the employer shall be liable for the payment of maternity benefit for the entire period of maternity benefit following the day of her delivery but if the child also dies during the said period, then, for the days upto and including the day of the death of the child.]
(2) The amount of maternity benefit for the period preceding the date of her expected delivery shall be paid in advance by the employer to the woman on production of a certificate in Form ‘B’ stating that she is pregnant and is expected to be delivered of a child within six weeks of the date of production of the certificate, and the amount due for the subsequent period shall be paid by the employer to the woman within forty-eight hours of production of the certificate in Form ‘B’ or Form ‘D’ stating that she has been delivered of a child or production of a certified extract from a Birth Register maintained under the provisions of any law for the time being in force.
4. (1) Any woman employed in an establishment and entitled to maternity benefit under the provisions of this Act may give notice in writing in Form ‘E’ to her employer, stating that her maternity benefit and any other amount to which she may be entitled under this Act may be paid to her or to such person as she may nominate in the notice and that she will not work in any establishment during the period for which she receives maternity benefit.
(2) In the case of a woman who is pregnant, such notice shall state the date from which she will be absent from work, not being a date earlier than six weeks from the date of her expected delivery.
(3) Any woman who has not given the notice when she was pregnant may give such notice as soon as possible after the delivery.
(4) On receipt of the notice, the employer shall permit such woman to absent herself from the establishment until the expiry [of the remaining period of maternity benefit] after the day of her delivery. 5. (1) Every woman entitled to maternity benefit under the Act shall also be entitled to receive from her employer a medical bonus of [two hundred and fifty rupees], if no pre-natal, confinement and post-natal care is provided for by the employer free of charge. The medical bonus shall be paid alongwith the second instalment of the maternity benefit. (2) In case of miscarriage, a woman shall, on production of a certificate in Form ‘B’ or Form ‘D’ be entitled to leave with wages at the rate of maternity benefit, for a period of six weeks immediately following the day of her miscarriage. The wages shall be paid within 48 hours of production of the certificate in Form ‘B’ or Form ‘D’.
[(2a) In case of medical termination of pregnancy, a woman shall, on production of a certificate in Form ‘B’ be entitled to leave with wages of the rate of maternity benefit for a period of six weeks immediately following the day of her medical termination of pregnancy. The wages shall be paid within 48 hours of production of the certificate in Form ‘B’.] (3) A woman suffering from illness arising out of pregnancy, delivery, premature birth of child or miscarriage/[medical termination of pregnancy or tubectomy operation] shall, on production of a certificate in Form ‘B’, be entitled, in addition to the period of absence allowed to her on account of maternity or miscarriage/[medical termination of pregnancy or tubectomy operation], as the case may be, to leave with wages at the rate of maternity benefit for a maximum period of one month. The wages for the leave period shall be paid within 48 hours of the expiry of that period. 6. Every woman delivered of a child who returns to duty after such delivery shall, in addition to the interval for rest allowed to her, be allowed in the course of her daily work two breaks of 15 minutes’ duration for nursing the child until the child attains the age of fifteen months. An extra sufficient period, depending upon the distance to be covered, shall be allowed for the purpose of the journey to and from the creche or the place where the children are left by women while on duty, provided that such extra period shall not be less than 5 minutes and more than 15 minutes’ duration.
7. (1) When a woman absents herself from work in accordance with the provisions of the Act, it shall be unlawful for her employer to discharge or dismiss her during or on account of such absence or to give notice of discharge or dismissal on such a day that the notice will expire during such absence, or to vary to her disadvantage any of the conditions of her service.
(2)(a) The discharge or dismissal of a woman at any time during her pregnancy, if the woman but for which discharge or dismissal would have been entitled to maternity benefit or medical bonus shall not have the effect of depriving her of the maternity benefit or medical bonus:
Provided that where the dismissal is for one or more of the following acts, the employer may, by order in writing communicate to the woman, deprive her of the maternity benefit or medical bonus or both—
(i) willful destruction of employer’s goods or property;
(ii) assaulting any superior or co-employee at the place of work;
(iii) criminal offence involving moral turpitude resulting in conviction in a court of law;
(iv) theft, fraud, or dishonesty in connection with the employer’s business or property; and
(v) willful non-observance of safety measures or rules on the subject or willful interference with safety devices or with fire-fighting equipment.
(b) Any woman deprived of maternity benefit or medical bonus or both, may within sixty days from the date on which the order of such deprivation is communicated to her, appeal in Form ‘G’ to [the Competent Authority and his decision] on such appeal whether the woman should or should not be deprived of maternity benefit or medical bonus or both, shall be final. 8. If a woman works in any establishment after she has been permitted by her employer to absent herself under the provisions of the Act, she shall forfeit her claim to the maternity benefit for such period.
9. (1) Any woman claiming the maternity benefit or any other amount to which she is entitled under the Act and any person claiming that payment due has been improperly withheld may make a complaint to the Inspector in writing in Form ‘H’ or ‘I’ as the case may be.
(2) The Inspector may, of his own motion or on receipt of a complaint in Form ‘H’ or I make an inquiry or cause an enquiry to be made and if satisfied that payment has been wrongfully withheld, may direct the payment to be made in accordance with his orders.
(3) Any person aggrieved by the decision of the Inspector may, within, thirty days from the date on which such decision is communicated to such person, appeal to [the Chief Inspector of Mines]. (4) The decision of [* * *] [the Competent Authority] where an appeal has been preferred to him or of the Inspector where no such appeal has been preferred, shall be final. 10. (a) The employer shall supply to every woman employed by him at her request free of cost copies of Forms ‘B’, ‘C’, ‘D’, ‘E’, ‘F’, ‘G’, ‘H’ and I.
(b) The failure to submit a notice, appeal or complaint in the prescribed form will not affect the right of a woman entitled to receive maternity benefit or any other amount due under the Act. Where a notice, appeal or complaint has been received in a form other than the prescribed form, the authority concerned shall within fifteen days of the receipt of such notice, appeal or complaint, require the woman to submit the notice, appeal or complaint, as the case may be in the prescribed form.
11. (a) (1) The employer of [every organisation] in which women are employed shall prepare and maintain a muster roll in Form ‘A’ and shall enter therein particulars of all women workers in [the organisation.] (2) All entries in the muster-roll shall be made in ink and maintained up-to-date and it shall always be available for inspection by the Inspector during working hours.
(b) The employer of [every organisation] shall on or before the 21st day of January in each year submit [* * *] [the Competent Authority] a return in each of the Forms ‘L’, ‘M’, ‘N’ and ‘O’, giving information as to the particulars specified in respect of the preceding year. FORM L
[See rule 16]
ANNUAL RETURN FOR THE YEAR ENDING ON THE 31ST DECEMBER, 19....
1. Name of [the organisation]………………………………………………………… 2. Situation of [the organisation] …………………………………………………….. MauzaDistrictStateNearest Railway Station………………………………………….
3. Date of opening of [the organisation]……………………………………………… 4. Date of closing, if closed………………………………………………………………
5. Postal address of [the organisation]……………………………………………….. 6. Name of employer………………………………………………………………………
Postal address of employer…………………………………………………………….
7. Name of managing agent, if any. Postal address of managing agent………………...
8. Name of Agent or representative of employer. Postal address of representative of employer………………………………………………………………………………..
9. Name of Manager………………………………………………………………………
Postal address of manager……………………………………………………………..
10. (a) Name of medical officer, attached to [the organisation]………………………. (b) Qualification of medical officer attached to [the organisation]…………………… (c) Is he resident at [the organisation] ?.............................................................. (d) If a part-time employee, how often does he pay visits to [the mine or circus]…... 11. (a) Is there any hospital at [the organisation]?................................................ (b) If so, how many beds are provided for women employees?
(c) Is there a lady doctor?
(d) If so, what are her qualifications ?
(e) Is there a qualified midwife ?
(f) Has any creche been provided ?
Signature of employer
Date............................
FORM M
[See rule 16]
EMPLOYMENT, DISMISSAL, PAYMENT OF BONUS, ETC., OF WOMEN FOR THE YEAR ENDING ON 31ST DECEMBER, 19.....
1. [Organisation]…………………………………………………………………….… 2. Aggregate number of women permanently or temporarily employed during the year… ………………………………………………………………………………….
3. Number of women who worked for a period of not less than [eighty days] in the twelve months immediately preceding the date of delivery………………………….. 4. Number of women who gave notice under section 6………………………………….
5. Number of women who were granted permission to remain absent on receipt of notice of confinement………………………………………………………………….
6. Number of claims for maternity benefit paid………………………………………….
7. Number of claims for maternity benefit rejected……………………………………..
8. Number of cases where pre-natal, confinement and post-natal care was provided by the management free of charge (section 8)…………………………………………..
9. Number of claims for medical bonus paid (section 8)…………………………………
10. Number of claims for medical bonus rejected…………………………………………
11. Number of cases in which leave for miscarriage/[MTP] was granted………………… 12. Number of cases in which leave for miscarriage/[MTP] was applied for but was rejected. ………………………………………………………………………………. [12a Number of cases in which leave for tubectomy operation under section 9A was granted………………………………………………………………………………… 12b. Number of cases in which leave for tubectomy operation was applied for but was rejected.]……………………………………………………………………………….
13. Number of cases in which additional leave for illness under section 10 was granted.
14. Number of cases in which additional leave for illness under section 10 was applied for but was rejected……………………………………………………………………
15. Number of women who died……………………………………………………………
(a) before delivery.
(b) after delivery.
16. Number of cases in which payment was made to persons other than the woman concerned………………………………………………………………………………
17. Number of women discharged or dismissed while working……………………………
18. Number of women deprived of maternity benefit and/or medical bonus under proviso to subsection (2) of section 12………………………………………………
19. Number of cases in which payment was made on the order of the Competent Authority or Inspector…………………………………………………………………
20. Remarks………………………………………………………………………………… ………………………………………………………………………………………….
N.B.—Full particulars of each case and reasons for the action taken under serials 7,10,12,14,17 and 18 should be given in Appendix below:—
Date................................... Signature of employer.
FORM N
[See rule 16]
DETAILS OF PAYMENT MADE DURING THE YEAR ENDING 31ST DECEMBER, 19.....
Name of person to whom paid……………………………. Amount paid………………
1. Date of payment…………………………………………………………………………
2. Woman employee………………………………………………………………………...
3. Nominee of the woman………………………………………………………………….
4. Legal representative of the woman……………………………………………………..
5. Amount for the period preceding date of expected delivery……………………….…..
6. Amount for the subsequent period……………………………………………….……..
7. Under section 8 of the Act………………………………………………………………
8. Under section 9 of the Act. …………………………………………………………….
[8a. Under section 9A of the Act.]……………………………………………………….. 9. Under section 10 of the Act…………………………………………………………….
10. Number of women workers who absconded after receiving the first instalment of maternity benefit………………………………………………………………………
11. Cases where claims were contested in a court of law…………………………………
12. Results of such cases…………………………………………………………………..
13. Remarks…………………………………………………………………………………
Signature of employer
Date....................................
FORM-O
[See rule 16]
PROSECUTION DURING THE YEAR ENDING 31ST DECEMBER, 19.....
Place of employment of Number of cases Number of cases
the woman employee instituted which resulted Remarks
------------------------------------------------------------------------------------------------------
(For mines)
N.B.—Reasons for prosecution should be given in full in the Appendix below:
Signature of employer.
Date............................................
Shaswat Kumar, Leader - HRT & Cloud, Deployment Solutions, APAC - Aon Hewitt
