DALOLATNOMA №
|
|
Ishlab chiqarishdagi baxtsiz hodisa va salomatlikka boshqa xil zarar yetkazilishi to‘g‘risida
|
1. Korxonaning nomi___________________________________________________________
|
1.1. Korxonaning manzili _______________________________________________________
|
|
(viloyat, shahar, tuman, ko‘cha, uy)
|
1.2. Mulkchilik shakli __________________________________________________________
|
|
(davlat, aksiyadorlik, xususiy va hokazo)
|
1.3. Baxtsiz hodisa yuz bergan joy _________________________________________________
|
|
(bo‘linma, sex)
|
2. Vazirlik, korporatsiya, uyushma, konsern __________________________________________
|
3. Xodimni yo‘llagan korxona ____________________________________________________
|
(nomi, manzili, vazirlik
|
____________________________________________________________________________
|
korporatsiya, uyushma, konsern)
|
4. Jabrlanuvchining familiyasi, ismi va otasining ismi _____________________________
|
____________________________________________________________________________
|
5. Jinsi: erkak, ayol (tagiga chizilsin)
|
6. Yoshi (to‘liq yillar soni ko‘rsatilsin) ____________________________________________
|
7. Kasbi, lavozimi _____________________________________________________________
|
7.1. Razryadi, klassi ____________________________________________________________
|
8. Baxtsiz hodisa yuz berganda bajarilayotgan ish bo‘yicha ish staji _______________________
____________________________________________________________________________
|
9. Mehnat xavfsizligi bo‘yicha yo‘riqnoma, o‘qitish:
|
9.1. Kirish yo‘riqnomasi (sana) ___________________________________________________
|
9.2. Mehnat xavfsizligi bo‘yicha o‘qitish (sana) _______________________________________
|
9.3. Dastlabki (davriy) yo‘riqnoma (sana) ___________________________________________
|
9.4. O‘ta xavfli ishlar uchun bilimlarni tekshirish (sana) ______________________________
____________________________________________________________________________
|
9.5. Ishga kirayotganida va davriy tibbiy ko‘rikdan o‘tganligi ___________________________
____________________________________________________________________________
|
10. Baxtsiz hodisa yuz bergan sana va vaqt____________________________________________
|
|
(yil, kun, oy)
|
____________________________________________________________________________
|
(ish boshlashdan to‘liq soatlar soni)
|
11. Baxtsiz hodisa holati ________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
|
11.1. Baxtsiz hodisa sabablari ___________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
|
11.2. Jarohat yetkazilishga sabab bo‘lgan asbob-uskuna _________________________________
____________________________________________________________________________
|
11.3. Jabrlanuvchining hushyorligi (alkogol yoki narkotiklar ta’siridaligi) _____________
__________________________________________________________________
|
(tibbiy xulosaga binoan)
|
11.4. Tashxis __________________________________________________________________
|
(dastlabki, oxirgi)
|
12. Baxtsiz hodisa sabablarini bartaraf etish tadbirlari:
|
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
|
13. Mehnat to‘g‘risidagi qonunchilik, mehnatni muhofaza qilish qoidalari va me’yorlari buzilishiga yo‘l qo‘ygan shaxslar __________________________________________________
|
(F.I.Sh., lavozimi, korxona nomi)
|
____________________________________________________________________________
|
(ular tomonidan buzilgan qonunlar, qoidalar va
|
____________________________________________________________________________
|
me’yoriy hujjatlarning moddalari, bandlari)
|
14. Baxtsiz hodisa guvohlari _____________________________________________________
|
Dalolatnoma tuzildi___________________________________________________________
|
(yil, kun, oy)
|
|
Komissiya raisi
|
_________________________________________
|
|
(F.I.Sh., imzo)
|
|
Komissiya a’zolari
|
___________________________________________
|
|
(F.I.Sh., imzo)
|
|
