.......................................................... ...............................................

(pieczęć adresowa pracodawcy) (miejscowość i data)

PROTOKÓŁ przesłuchania poszkodowanego/świadka*

sporządzony w związku z wypadkiem z dnia...

(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:..........

..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

* Niepotrzebne skreślić

.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. Na tym protokół zakończono i po odczytaniu zgodnie podpisano.

.............................................................. ...............................................................

(podpis i pieczęć prowadzącego przesłuchanie) (podpis przesłuchiwanego/ej)

http:\\www.andber.republika.pl

2

---