APROB

Conductorul unitii
___________________________
(semntura i descifrarea semnturii)

_____________________200_
tampila unitii
PROCES-VERBAL nr._________
privind cercetarea accidentului de munc cu incapacitate temporar de munc
1. Denumirea unitii (numele, prenumele, patronimicul angajatorului - persoan fizic) n care (la care)
s-a produs accidentul ________________________________________________________________________
__________________________________________________________________________________________
1.1 Adresa unitii (angajatorului - persoan fizic)___________________________________________________
1.2 Forul superior ____________________________________________________________________________
1.3 Activitatea economic ______________________________________________________________________
__________________________________________________________________________________________
1.4 Forma de proprietate_______________________________________________________________________
(public, privat)

1.5 Numrul de angajai la unitate (angajator - persoan fizic) ____________ inclusiv _________ femei
1.6 Secia, sectorul, locul unde s-a produs accidentul_________________________________________________
2.0 Denumirea unitii (numele, prenumele, patronimicul angajatorului - persoan fizic) al crei (crui)
a fost / este accidentatul _______________________________________________________________________
2.1 Adresa unitii (numele, prenumele, patronimicul angajatorului persoan fizic) _________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3. Datele de identificare ale accidentatului:
3.1 Numele, prenumele, patronimicul _____________________________________________________________
__________________________________________________________________________________________
3.2 Adresa de la domiciliu ______________________________________________________________________
__________________________________________________________________________________________
3.3 Sexul ___________________________________________________________________________________
(masculin, feminin)

3.4 Vrsta (ani complei) ________________________________________________________________________

3.5 Funcia, profesia, meseria ___________________________________________________________________
__________________________________________________________________________________________
3.6 Vechimea n funcia, profesia, meseria exercitat n timpul accidentrii ________________________________
3.7 Instruirea n domeniul proteciei muncii ________________________________________________________
(data, nu s-a efectuat, nu este necesar)

3.7.1 Instruirea suplimentar n domeniul proteciei muncii ____________________________________________

(data, nu s-a efectuat, nu este necesar)

3.7.2 Instructajul la locul de munc sau periodic ___________________________________________________

(data, nu s-a efectuat)

3.8 Controlul medical

3.8.1 Controlul medical la ncadrarea n munc_____________________________________________________
(data, nu s-a efectuat)

__________________________________________________________________________________________
3.8.2. Controlul medical periodic ________________________________________________________________
(data, nu s-a efectuat, nu este necesar)

__________________________________________________________________________________________
4. Data i ora producerii accidentului _____________________________________________________________
5. Clasificarea accidentului _____________________________________________________________________
(individual, colectiv)

6. Descrierea detaliat a locului i a circumstanelor n care s-a produs accidentul_________________________

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
6.1 Clasificarea circumstanelor care au condus la producerea accidentului _______________________________
__________________________________________________________________________________________
(cdere, prindere, lovire, strivire, explozii, incendii, atac criminal, contact cu curent electric etc.)

7. Cauzele producerii accidentului dependente de:

7.1 executant _______________________________________________________________________________
(nclcarea disciplinei de munc i a instruciunilor, nefolosirea echipamentului de protecie etc.)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
7.2 mijloace de producie ______________________________________________________________________
(defecte sau imperfeciuni ale utilajului, starea tehnic a cldirilor i a drumurilor)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
7.3 sarcina de munc _________________________________________________________________________
(lacune n organizarea locurilor de munc i a lucrrilor, lacune n instruirea personalului etc.)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
7.4 mediul de munc _________________________________________________________________________
(concentraia prafului i a gazului, temperatura, umiditatea aerului, nivelul de iluminare etc.)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Diagnoza vtmrii organismului ________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(se transcrie din certificatul eliberat de instituia medical)

8. Persoanele care au nclcat prevederile actelor legislative i altor acte normative din domeniul muncii
__________________________________________________________________________________________
(numele, prenumele, articolele nclcate din actele normative)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

9. Msurile de lichidare a cauzelor de producere a accidentului i de prevenire a unor eventuale evenimente similare:
Nr.
d/o

Denumirea msurilor

Termen de realizare

Responsabil de realizare

Note

Procesul-verbal a fost ntocmit la ___________________________200_ de ctre comisia de cercetare:

Preedintele comisiei ___________________________________
(numele, prenumele)

membrul comisiei _____________________________________

(numele, prenumele)

membrul comisiei _______________________________________

(numele, prenumele)

membrul comisiei ______________________________________

(numele, prenumele)

______________________
(semntura)

________________________
(semntura)

________________________
(semntura)

________________________
(semntura)

MINISTERUL ECONOMIEI I COMERULUI

AL REPUBLICII MOLDOVA

INSPECIA MUNCII

INSPECTORATUL TERITORIAL DE MUNC

_____________________________________

_____________________________________

PROCES-VERBAL nr._________
privind cercetarea accidentului de munc ________________________
(tipul)

1. Denumirea unitii (numele, prenumele, patronimicul angajatorului - persoan fizic) n care (la care)
s-a produs accidentul _________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
1.1 Adresa unitii (angajatorului - persoan fizic) ___________________________________________________
__________________________________________________________________________________________
1.2 Forul superior ____________________________________________________________________________
1.3 Activitatea economic ______________________________________________________________________
__________________________________________________________________________________________
1.4 Forma de proprietate _______________________________________________________________________
(public, privat)

1.5 Codul fiscal / IDNO sau IDNP _________________________ Certificatul de nregistrare:

seria_____ nr. _______________ eliberat la _____ ____________________ 200_
1.6 Numrul de angajai la unitate (angajator - persoan fizic) ____________ inclusiv _________ femei
1.7 Secia, sectorul, locul unde s-a produs accidentul________________________________________________
2.0 Denumirea unitii (numele, prenumele, patronimicul angajatorului - persoan fizic) al crei (crui)
a fost / este accidentatul _______________________________________________________________________
2.1 Adresa unitii (numele, prenumele, patronimicul angajatorului persoan fizic) _________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3. Datele de identificare ale accidentatului:
3.1 Numele, prenumele, patronimicul _____________________________________________________________
__________________________________________________________________________________________
3.2 Adresa de la domiciliu ______________________________________________________________________
__________________________________________________________________________________________
3.3 Sexul ___________________________________________________________________________________
(masculin, feminin)

3.4 Vrsta (ani complei) ________________________________________________________________________

3.5 Funcia, profesia, meseria ___________________________________________________________________
__________________________________________________________________________________________
3.6 Vechimea n funcia, profesia, meseria exercitat n timpul accidentrii ________________________________
3.7 Instruirea n domeniul proteciei muncii _________________________________________________________
(data, nu s-a efectuat, nu este necesar)

3.7.1 Instruirea suplimentar n domeniul proteciei muncii _____________________________________________

(data, nu s-a efectuat, nu este necesar)

3.7.2 Instructajul la locul de munc sau periodic _____________________________________________________

(data, nu s-a efectuat)

3.8 Controlul medical

3.8.1 Controlul medical la ncadrarea n munc______________________________________________________
(data, nu s-a efectuat)

__________________________________________________________________________________________
3.8.2. Controlul medical periodic _________________________________________________________________
(data, nu s-a efectuat, nu este necesar)

__________________________________________________________________________________________
4. Data i ora producerii accidentului _____________________________________________________________
5. Clasificarea accidentului _____________________________________________________________________
(individual, colectiv)

6. Descrierea detaliat a locului i a circumstanelor n care s-a produs accidentul__________________________

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
6.1 Clasificarea circumstanelor care au condus la producerea accidentului ______________________________
__________________________________________________________________________________________
(cdere, prindere, lovire, strivire, explozii, incendii, atac criminal, contact cu curent electric etc.)

7. Cauzele producerii accidentului dependente de:

7.1 executant _______________________________________________________________________________
(nclcarea disciplinei de munc i a instruciunilor, nefolosirea echipamentului de protecie etc.)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
7.2 mijloace de producie ______________________________________________________________________
(defecte sau imperfeciuni ale utilajului, starea tehnic a cldirilor i a drumurilor)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
7.3 sarcina de munc _________________________________________________________________________
(lacune n organizarea locurilor de munc i a lucrrilor, lacune n instruirea personalului etc.)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
7.4 mediul de munc _________________________________________________________________________
(concentraia prafului i a gazului, temperatura, umiditatea aerului, nivelul de iluminare etc.)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Diagnoza vtmrii organismului ________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(se transcrie din certificatul eliberat de instituia medical)

8. Persoanele care au nclcat prevederile actelor legislative i altor acte normative din
domeniul muncii _____________________________________________________________________________
(numele, prenumele, articolele nclcate din actele normative)

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

9. Msuri de lichidare a cauzelor de producere a accidentului i de prevenire a unor eventuale evenimente similare:
Nr.
d/o

Denumirea msurilor

Termen de realizare

Procesul-verbal a fost ntocmit la ___________________________200_ de ctre

inspectorul de munc ___________________________________

Note

________________________
(semntura)

(numele, prenumele)

_________________

Responsabil de realizare

La cercetare au participat:
_____________________________________

________________________

(funcia)

(numele, prenumele)

(semntura)

_________________

_______________________________________

________________________

(funcia)

(numele, prenumele)

(semntura)

_________________

_______________________________________

________________________

(funcia)

(numele, prenumele)

(semntura)

_________________

_______________________________________

________________________

(funcia)

(numele, prenumele)

(semntura)

_________________

_______________________________________

________________________

(funcia)

(numele, prenumele)

(semntura)