DALOLATNOMA №
Ishlab chiqarishdagi baxtsiz hodisa va salomatlikka boshqa xil zarar yetkazilishi
to‘g‘risida
1. Korxonaning nomi__________________________________________________
1.1. Korxonaning manzili
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(viloyat, shahar, tuman, ko‘cha, uy)
1.2. Mulkchilik shakli
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(davlat, aksiyadorlik, xususiy va h.k)
1.3. Baxtsiz hodisa yuz bergan joy
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(bo‘linma, sex)
2. Vazirlik, xo‘jalik boshqaruvi organi
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3. Xodimni yo‘llagan korxona
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(nomi, manzili, vazirlik
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xo‘jalik boshqaruvi organi)
4. Jabrlanuvchining familiyasi, ismi va otasining ismi
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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
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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)
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9.5. Ishga kirayotganida va davriy tibbiy ko‘rikdan o‘tganligi
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10. Baxtsiz hodisa yuz bergan sana va
vaqt_____________________________________________________________________
(yil, kun, oy)
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(ish boshlashdan to‘liq soatlar soni)
11. Baxtsiz hodisa holati ________________________________________________
11.1. Baxtsiz hodisa sabablari ____________________________________________
11.2. Jarohat yetkazilishga sabab bo‘lgan asbob-uskuna
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11.3. Jabrlanuvchining hushyorligi (alkogol yoki narkotiklar ta’siridaligi)
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(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
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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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