FORM ‘A’
(See Rule3)
MUSTER ROLL
Name of establishment __________________
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 Number of days Number of days Number of days Remarks
Employed laid off not employed
6. Date of which the woman gives notice under Section 6.
7. Date of discharge or 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 or miscarriage or 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 medical bonus, if paid under Section 8.
15. Date with the amount of wages paid on account of leave under Section 9
16. Date with amount of wages paid on account of leave under Section 10 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 child and the period for which
it was paid.
20. Signature of the employer of the establishment attenuating the entries in the
muster roll.
21. Remarks column for the use of the Inspector.
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