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TASDIQLAYMAN”
N-1 shakli
Ish beruvchi
Bir nusxadan yuboriladi:
________________________
(imzo, imzo yoyilmasi)
— jabrlanuvchiga (o‘lgan bo‘lsa oilasiga);19 _ yil __________________— mehnatni muhofaza qilish xizmati rahbari (muhandisi, mutaxassisi)ga;korxona muhri— bosh davlat mehnat texnika nazoratchisiga
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, 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 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)
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