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 ____________________________
________________________________
________________________________
____________