Anexa 9

Anexa 8FORMULAR PENTRU INREGISTRAREA,COMUNICAREA ACCIDENTULUI/

EVENIMENTULUI nr.________din ____________________

1.ELEMENTE DE IDENTIFICARE :1.1 Nume victima: ________________________________________________________ 1.1.1 Cod numeric personal:_________________

1.1.2 Varsta____________________

1.1.3 Profesia:______________________________

1.1.4 Starea civila:______________________

1.1.5 Copii minori:____________________

1.2 Domiciliul :__________________________________________________________

1.3 Societatea unde este angajat :____________________________________________

1.4 Locul de munca unde s-a produs accidentul :________________________________

1.4.1 Data si ora accidentului: ____________________________________________

1.5 Descrierea evenimentului :

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

1.6 Urmarile evenimentului:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

1.7 Cine a comunicat :_____________________________________________________

Functia :___________________________ Tel:___________________________

1.8 Data si ora comunicarii :_________________________________________________

2. RESPONSABILITATI2.1 Cine a primit comunicarea :______________________________________________

2.2 Cod CAEN unitate :____________________________________________________

2.3 Cine a identificat/ controlat unitatea :______________________________________

3. REPARTIZARE PENTRU VERIFICARE,SOLUTIONARE SI RELATII3.1 Apreciere :daca este cazul deplasarii la fata locului : da / nu

PAGE 212