(davlat, aksiyadorlik, xususiy va h.k)
1.3. Baxtsiz hodisa yuz bergan joy
__________________________________________________________________________
(bo‘linma, sex)
2. Vazirlik, xo‘jalik
boshqaruvi organi
__________________________________________________________________________
3. Xodimni yo‘llagan korxona
__________________________________________________________________________
(nomi, manzili, vazirlik
___________________________________________________________________
______
xo‘jalik boshqaruvi organi) 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
meyorlari 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
_______________________
____________________________
____________________________
_________________________
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