........................................ .....................................(pieczęć adresowa pracodawcy) (miejscowość i data)
PROTOKÓŁ przesłuchania poszkodowanego
sporządzony w związku z wypadkiem z dnia.......................................
Sporządzony dnia ............................... w ................................................................przez zespół powypadkowy w składzie:
a) .......................................................... ..............................................................b) .......................................................... .............................................................. (Imię i nazwisko) (funkcja)
Poszkodowany(a)
1. Imię i nazwisko ......................................................................................................
2. Imię ojca .................................................................................................................3. Data i miejsce urodzenia ........................................................................................4. Dowód osobisty (seria i nr) ....................................................................................5. PESEL ....................................................................................................................6. Miejsce zatrudnienia ..............................................................................................7. Stanowisko służbowe .............................................................................................8. Adres zamieszkania ................................................................................................Zeznanie................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................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Na tym protokół zakończono i po odczytaniu zgodnie podpisano.
Podpisy członków zespołu powypadkowego1) .................................................................................2) .................................................................................
.......................................................
(podpis poszkodowanego)
2
dankatamiola