“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 | | — hududiy mehnat organining Davlat mehnat inspeksiyasiga |
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| 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: |
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
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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) | |