Nothing to worry in its columns,
Only thing u have to confirm whether the employee is on leave/strike on paid wages with or with out wages against the period mentioned in the front side by taking the details from ur attendance and wages register. The same should be reflected at back side of the form and submit the same to the concerned branch manager.
The form 10 is called form for abestention verification of the Insured Person. Since Insured Person is not supposed to draw any wages during the certified leave under ESI.
Hope I cleared ur doubt....