32
4.
Jabrlanuvchining
familiyasi,
ismi,
otasining
ismi
_____________________________
_____________________________________________________________________
___
5.
Jinsi, erkak, ayol (tagiga chizilsin)
6.
Yoshi
(to’liq,
yillar
soni
ko’rsatilsin)
_______________________________________
7.
Kasbi
lavozimi
________________________________________________________
7.1.
Gazarazryadi,
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.
Birlamchi
(davriy)
yo’riqnoma
(sana)
______________________________________
9.4.
O’ta
xavfli
ishlar
uchun
bo’limlarni
tekshirish
(sana)
__________________________
9.5.
Ishga
kirayotganda
va
davriy
tibbiy
ko’rikdan
o’tganligi
_______________________
10.
Baxtsiz
hodisa
yuz
bergan
sana
va
vaqt
_____________________________________
(yil, kun, oy)
_____________________________________________________________________
___
(ish boshlashdagi to’liq soatlar soni)
11.
Baxtsiz
hodisa
holati
___________________________________________________
_____________________________________________________________________
___
_____________________________________________________________________
___
11.1. Baxtsiz
hodisa sabablari
_______________________________________________
33
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_______________
11.2. Jarohat yetkazilishiga sabab bo’lgan asbob-uskuna
_____________________________
11.3. Jabrlanuvchining hushyorligi (alkogol yoki narkotik ta’siridaligi)
_____________________________________________________________________
_____
(tibbiy xulosaga binoan)
11.4. Tashxis
_______________________________________________________________
(dastlabki, oxirgi)
12.
Baxtsiz hodisa sabablarini bartaraf etish tadbirlari:
t/r
Tadbirlar nomi
Bajarish
muddati
Bajaruvchi
Bajarilishi
haqidagi
belgi
13.
Mehnat to’g’risidagi qonunchilik, mehnatni muhofaza qilish qoidalari va
me’yorlari buzilishiga yo’l qo’ygan shaxslar
_____________________________________________________________________
___
(F.I.O, lavozimi korxona nomi)
_____________________________________________________________________
___
(ular
tomonidan buzilgan qonunlar, qoidalar va me’yoriy hujjatlarning moddalari,
bandlari)
14.
Baxtsiz hodisa guvohlari
__________________________________________________
Dalolatnoma
tuzildi
_________________________________________________________
(yil, kun, oy)
34
Komissiya
raisi
_____________________________________________________________
(F.I.O. imzo)
Komissiya a’zolari
___________________________________________________________
(F.I.O. imzo)
Komissiya a’zolari
___________________________________________________________
(F.I.O. imzo)
Komissiya a’zolari
___________________________________________________________
(F.I.O. imzo)
Komissiya a’zolari
___________________________________________________________
(F.I.O. imzo)
