Miejscowość ..................................................., dnia ................................

WYJAŚNIENIA

UZYSKANE OD POSZKODOWANEGO

w wypadku przy pracy, zrównanym z wypadkiem przy pracy, przy wykonywaniu umowy agencyjnej lub umowy zlecenia*,  któremu

uległ(a) w dniu .......................................... o godz. ........................ Pan(i) .......................................................................................................................................

(nazwisko i imię poszkodowanego)

POSZKODOWANY(A):

Nazwisko i imię ...................................................................................................................................... Imię ojca ............................................................................

Data i miejsce urodzenia ..........................................................................................................................................................................................................................

Miejsce zamieszkania ...............................................................................................................................................................................................................................

Zatrudniony(a) .................................................................................................................................. Staż pracy w obecnym zakładzie pracy .......................

(dział, wydział)

Stanowisko .................................................................................................................................................................... Staż pracy na stanowisku .......................

(nazwa)

Zespół powypadkowy w składzie:

1.       .............................................................................................................................................................................................................................................. Członek

(nazwisko i imię)                                                                                    (stanowisko)

2.       .............................................................................................................................................................................................................................................. Członek

(nazwisko i imię)                                                                                    (stanowisko)

Poszkodowany wyjaśnia co następuje:

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*) niepotrzebne skreślić                                                                                                                                                                        - verte-

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Na tym zakończono i po osobistym odczytaniu, jako zgodne z moimi wyjaśnieniami podpisuję:

.......................................................................................                                                               1. ...........................................................................................

(podpis poszkodowanego)                                                                                          

  2. .............................................................................................

(podpisy zespołu powypadkowego)

str. 1