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  (pieczęć adresowa pracodawcy) 

(miejscowość i data)

PROTOKÓŁ 

przesłuchania poszkodowanego/świadka*

(wypadek w drodze do lub z pracy)

Pan/Pani ................................................................ imię ojca ...................................... 
data urodzenia ........................................ miejsce urodzenia ...................................... 

zamieszkały(a): ul. ..................................................... nr domu/mieszkania ............... 
zatrudniony(a) .............................................................................................................

(nazwa zakładu pracy)

na stanowisku ..............................................................................................................
legitymujący(a) się dowodem osobistym: seria .............. nr .......................................
(uprzedzony(a) o odpowiedzialności karnej z art. 233 Kodeksu karnego za 
składanie fałszywych zeznań lub zatajenie prawdy)* zeznaje co następuje:...............
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* Niepotrzebne skreślić

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Na tym protokół zakończono i po odczytaniu zgodnie podpisano.

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 (podpis i pieczęć prowadzącego przesłuchanie)  

       (podpis przesłuchiwanego/ej)