O‘zbekiston Respublikasi Vazirlar Mahkamasining qarori, 06. 06

(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, korporatsiya, uyushma, konsern __________________________________________
3. Xodimni yo‘llagan korxona ____________________________________________________
(nomi, manzili, vazirlik
____________________________________________________________________________
korporatsiya, uyushma, konsern)
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) _____________
__________________________________________________________________