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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)