“TASDIQLAYMAN” | N-1 shakli | |
Ish beruvchi | Bir nusxadan yuboriladi: | |
____________________________ | — 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) _____________ __________________________________________________________________ | ||
(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 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) | ||
| _________________________________________ | |
(F.I.Sh., imzo) | ||
Komissiya a’zolari | ___________________________________________ | |
(F.I.Sh., imzo) |
19 ___ yil “____” ____________________ soat _________________________ minutda | |||
_____________________________________________________________________________ | |||
(jabrlanuvchining familiyasi, ismi, otasining ismi) | |||
bilan yuz bergan ________________________________________________________________ | |||
(guruhiy, o‘lim bilan tugagan, oqibati og‘ir) | |||
_____________________________________________________________________________ | |||
(kasbi, lavozimi, ish joyi, | |||
_____________________________________________________________________________ | |||
korxona, yuqori turuvchi xo‘jalik organi, vazirlik, | |||
_____________________________________________________________________________ | |||
korporatsiya, uyushma, konsern nomi) | |||
_____________________________________________________________________________ | |||
(buyruq) | |||
asosan quyidagi tarkibda tuzilgan komissiya: | |||
rais ________________________________________________________________________ | |||
(F.I.Sh., lavozimi, ish joyi) | |||
_____________________________________________________________________________ | |||
komissiya a’zolari: _____________________________________________________________ | |||
(F.I.Sh., lavozimi, ish joyi) | |||
_____________________________________________________________________________ | |||
taklif etilgan mutaxassislar ishtirokida ___________________________________________ ______________________________________________________________________________ | |||
(F.I.Sh., lavozimi, ish joyi) | |||
19 ___ y. “________” ______________ dan 19 ___ y. “______” gacha mazkur baxtsiz hodisani maxsus tekshirdi va ushbu dalolatnomani tuzdi. |
Komissiya raisi | _________________________________ | ||
(F.I.Sh., sana, imzo) | |||
Komissiya a’zolari | _________________________________ | ||
(F.I.Sh., sana, imzo) |
19 ___yil “___” _____ soat ______ minutdagi | |||
____________________________________________________________________________ | |||
(jabrlanuvchining familiyasi, ismi, otasining ismi) | |||
____________________________________________________________________________ | |||
(jabrlanuvchining lavozimi yoki kasbi, korxona, yuqori turuvchi xo‘jalik | |||
____________________________________________________________________________ | |||
organi, vazirlik, korporatsiya, uyushma, konsern nomi, jabrlanuvchining lavozimi yoki kasbi) | |||
Komissiya tomonidan ___________ yildan ______________ yilgacha o‘tkazilgan maxsus tekshirish materiallari asosida quyidagi xulosaga keldim, ya’ni _______________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ |