(Muassasa shtampi) | 094\x shakl | ||||
Mastlik holati bo‘yicha mehnatga layoqatsizlik | |||||
20___ yil “___” _____________ | ___________-son | ||||
Familiyasi, ismi_________________________________________________________ | |||||
(tashkilot nomi) | |||||
Tashxis _________________________________________________________________ Yakuniy tashxis ___________________________________________________________ Layoqatsizlik turi _________________________________________________ | |||||
(kasallik, ishlab chiqarishdagi, turmushdagi baxtsiz hodisalar) | |||||
Tartib _________________________________________________________________ | |||||
(ambulator yoki statsionar) | |||||
Shifoxonada bo‘lgan davri | 20___ yil “_____” __________________ 20___ yil “_____” ________________dan 20___ yil “_____” _______________ gacha | ||||
TIEKga yo‘llangan sana | 20___ yil “_____” _________________ | ||||
Shifokorning imzosi | __________ | ||||
TIEK ko‘rigidan o‘tgan sana | 20___ yil “_____” ___________________ | ||||
TIEK xulosasi | __________ | ||||
Vaqtincha boshqa ishga o‘tkazilsin | 20___ yil “_____” _______________ dan 20___ yil “_____” _______________ gacha | ||||
Bosh shifokor imzosi | __________ | ||||
TIEK raisining imzosi va TIEK muhri | __________ | ||||
Ishdan ozod etilgan kunlar (shu kunlar bilan birga) | 20___ yil “_____” _______________ dan 20___ yil “_____” _______________ gacha | ||||
Shifokorning F.I.O. | ______________________________ | ||||
Shifokorning imzosi | __________ | ||||
Ishga tushish sanasi (so‘z bilan yoziladi) | ______________________________ | ||||
Yangi ma’lumotnoma berildi | 20___ yil “_____” _________________ da | ||||
___________-son | |||||
Davolash-profilaktika muassasasi muhri | |||||
”. |