Yengil sanoat

______________________

korxona rahbari

“______” ___________ 2014 yil

DALOLATNOMA № _____
Ishlab chiqarishdagi baxtsiz hodisalarni va xodimlar salomatligining boshqa xil zararlanishini tekshirish to’g’risida

1. 
   Korxona nomi ______________________________________________________
   
   1. 
      Korxonaning manzili ________________________________________________
      

(viloyat, shahar, tuman, ko’cha, uy)

2. 
   Mulkchilik shakli ___________________________________________________
   

(davlat aktsiyadorlik, xususiy va x.)

3. 
   Baxtsiz hodisa yuz bergan joy _________________________________________
   

(bo’linma, sex)

2. 
   Vazirlik, korporasiya, uyushma, konsern __________________________________
   
3. 
   Xodimni yo’llagan korxona ____________________________________________
   

(nomi, manzili, vazirlik)

______________________________________________________________________

(korporasiya, uyushma, konsern)

4. 
   Jabrlanuvchining familiyasi, ismi, otasining ismi _____________________________
   

________________________________________________________________________

5. 
   Jinsi, erkak, ayol (tagiga chizilsin)
   
6. 
   Yoshi (to’liq, yillar soni ko’rsatilsin) _______________________________________
   
7. 
   Kasbi lavozimi ________________________________________________________
   
   1. 
      Gazarazryadi, klassi ____________________________________________________
      
8. 
   Baxtsiz hodisa yuz berganda bajarilayotgan ish bo’yicha ish staji _________________
   
9. 
   Mehnat xavfsizligi bo’yicha yo’riqnoma o’qitish:
   
   1. 
      Kirish yo’riqnomasi (sana) _______________________________________________
      
   2. 
      Mehnat xavfsizligi bo’yicha o’qitish (sana) __________________________________
      
   3. 
      Birlamchi (davriy) yo’riqnoma (sana) ______________________________________
      
   4. 
      O’ta xavfli ishlar uchun bo’limlarni tekshirish (sana) __________________________
      
   5. 
      Ishga kirayotganda va davriy tibbiy ko’rikdan o’tganligi _______________________
      
10. 
    Baxtsiz hodisa yuz bergan sana va vaqt _____________________________________
    

(yil, kun, oy)

________________________________________________________________________

(ish boshlashdagi to’liq soatlar soni)

11. 
    Baxtsiz hodisa holati ___________________________________________________
    

________________________________________________________________________

________________________________________________________________________

11.1. Baxtsiz hodisa sabablari _______________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________

11.2. Jarohat yetkazilishiga sabab bo’lgan asbob-uskuna _____________________________

11.3. Jabrlanuvchining hushyorligi (alkogol yoki narkotik ta’siridaligi) __________________________________________________________________________

(tibbiy xulosaga binoan)

11.4. Tashxis _______________________________________________________________

(dastlabki, oxirgi)

12. 
    Baxtsiz hodisa sabablarini bartaraf etish tadbirlari:
    

t/r	Tadbirlar nomi	Bajarish muddati	Bajaruvchi	Bajarilishi haqidagi belgi

13. 
    Mehnat to’g’risidagi qonunchilik, mehnatni muhofaza qilish qoidalari va me’yorlari buzilishiga yo’l qo’ygan shaxslar
    

________________________________________________________________________

(F.I.O, 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.O. imzo)

Komissiya a’zolari ___________________________________________________________

(F.I.O. imzo)

Komissiya a’zolari ___________________________________________________________

(F.I.O. imzo)

Komissiya a’zolari ___________________________________________________________

(F.I.O. imzo)

Komissiya a’zolari ___________________________________________________________

(F.I.O. imzo)

N-1 shaklidagi dalolatnomani