“TASDIQLAYMAN”
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N-1 shakli
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Ish beruvchi
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Bir nusxadan yuboriladi:
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____________________________
(imzo, imzo yoyilmasi)
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— jabrlanuvchiga (o‘lgan bo‘lsa oilasiga);
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20 _____ yil ______________________
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— mehnatni muhofaza qilish xizmati rahbari (muhandisi, mutaxassisi)ga;
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korxona muhri
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— bosh davlat mehnat texnika nazoratchisiga
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DALOLATNOMA №
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Ishlab chiqarishdagi baxtsiz hodisa va salomatlikka boshqa xil zarar yetkazilishi to‘g‘risida
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1. Korxonaning nomi___________________________________________________________
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1.1. Korxonaning manzili _______________________________________________________
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(viloyat, shahar, tuman, ko‘cha, uy)
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1.2. Mulkchilik shakli __________________________________________________________
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(davlat, aksiyadorlik, xususiy va hokazo)
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1.3. Baxtsiz hodisa yuz bergan joy _________________________________________________
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(bo‘linma, sex)
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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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____________________________________________________________________________
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xo‘jalik boshqaruvi organi)
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4. Jabrlanuvchining familiyasi, ismi va otasining ismi _____________________________
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____________________________________________________________________________
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5. Jinsi: erkak, ayol (tagiga chizilsin)
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6. Yoshi (to‘liq yillar soni ko‘rsatilsin) ____________________________________________
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7. Kasbi, lavozimi _____________________________________________________________
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7.1. Razryadi, klassi ____________________________________________________________
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8. Baxtsiz hodisa yuz berganda bajarilayotgan ish bo‘yicha ish staji _______________________
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9. Mehnat xavfsizligi bo‘yicha yo‘riqnoma, o‘qitish:
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9.1. Kirish yo‘riqnomasi (sana) ___________________________________________________
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9.2. Mehnat xavfsizligi bo‘yicha o‘qitish (sana) _______________________________________
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9.3. Dastlabki (davriy) yo‘riqnoma (sana) ___________________________________________
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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____________________________________________
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(yil, kun, oy)
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____________________________________________________________________________
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(ish boshlashdan to‘liq soatlar soni)
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11. Baxtsiz hodisa holati ________________________________________________________
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11.1. Baxtsiz hodisa sabablari ___________________________________________________
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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)
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11.4. Tashxis __________________________________________________________________
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(dastlabki, oxirgi)
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12. Baxtsiz hodisa sabablarini bartaraf etish tadbirlari:
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____________________________________________________________________________
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13. Mehnat to‘g‘risidagi qonunchilik, mehnatni muhofaza qilish qoidalari va me’yorlari buzilishiga yo‘l qo‘ygan shaxslar __________________________________________________
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(F.I.Sh., lavozimi, korxona nomi)
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(ular tomonidan buzilgan qonunlar, qoidalar va
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me’yoriy hujjatlarning moddalari, bandlari)
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14. Baxtsiz hodisa guvohlari _____________________________________________________
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Dalolatnoma tuzildi___________________________________________________________
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(yil, kun, oy)
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Komissiya raisi
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(F.I.Sh., imzo)
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Komissiya a’zolari
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(F.I.Sh., imzo)
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