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 xo‘jalik boshqaruvi organi)
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4. Jabrlanuvchining familiyasi, ismi va otasining ismi
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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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(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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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 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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