......................................................................... ........................................................................
(imię i nazwisko zgłaszającego) (miejscowość i data)
.........................................................................
(miejsce pracy)
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(stanowisko służbowe)
Zawiadomienie o wypadku przy pracy/wypadku w drodze do pracy/z pracy
Imię i nazwisko osoby poszkodowanej:...............................................................................................................
Miejsce pracy:......................................................................................................................................................
(zakład pracy, oddział, wydział)
Adres zamieszkania, numer telefonu:..................................................................................................................
Data i godzina wypadku:......................................................................................................................................
Miejsce wypadku:................................................................................................................................................
Skutki wypadku:...................................................................................................................................................
..............................................................................................................................................................................
Świadkowie wypadku (imię, nazwisko, adres zamieszkania, numer telefonu):
.......................................................................................................................................................................
......................................................................................................................................................................,
..............................................................................................................................................................................................................................................................................................................................................
Zwięzły opis wypadku:
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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........................................................................
(podpis osoby zgłaszającej wypadek)