Gua Tcnica de Prevencin (GTP) 1:

Delegados o Delegadas de Prevencin

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PLANILLA PARA EL REGISTRO DE DELEGADOS O DELEGADAS DE PREVENCIN

REGISTRO
ACTUALIZACIN DE DATOS

SOLO PARA EL USO DEL INPSASEL

UBICACIN GEOGRFICA
ENTIDAD
MUNICIPIO
EMPRESA

NMERO DE IDENTIFICACIN DEL REGISTRO DEL DELEGADO O DELEGADA

OCUPACIN
GRAN DIVISIN
DIVISIN

INSTITUCIN

CONTRATISTA

ACTIVIDAD ECONMICA (CDIGO CIUU)

GRAN DIVISIN
DIVISIN
AGRUPACIN

INTERMEDIARIO

ETT

SECTOR
PRODUCTIVO

CORRELATIVO

COOPERATIVA

I. DATOS DEL DELEGADO O DELEGADA DE PREVENCIN

1. NOMBRES Y APELLIDOS:
2. CDULA DE IDENTIDAD: V

AGRUPACIN

3. FECHA DE NACIMIENTO:

4. FECHA EN LA QUE FU ELECTO:

5. NMERO DE VOTOS CON LOS QUE FU ELECTO:

6. FECHA EN LA QUE SE AUTORIZ EL REGISTRO DEL COMIT(SOLO EN CASO DE ACTUALIZACIN DE DATOS) :

7. GRADO DE INSTRUCCIN:

8.- TTULO OBTENIDO

9. OCUPACIN:
10. DIRECCIN DE HABITACIN:
a. ESTADO:
b. MUNICIPIO:

c. PARROQUIA:

d. PUNTO DE REFERENCIA:
e. TELFONO HABITACIN:

f. TELFONO CELULAR:

g. E-mail:

II. DATOS RELATIVOS AL CENTRO DE TRABAJO/ESTABLECIMIENTO/UNIDAD DE EXPLOTACIN

1. NOMBRE DEL CENTRO DE TRABAJO/ESTABLECIMIENTO/UNIDAD DE EXPLOTACIN:

2. NMERO DEL RIF:

3. NMERO DEL NIT:

5.NMERO DEL IVSS:

6. DIRECCIN DEL CENTRO DE TRABAJO/ESTABLECIMIENTO/UNIDAD DE EXPLOTACIN:

a. ESTADO:

d. TELFONO:

4. NMERO DE TRABAJADORES:

b. MUNICIPIO:

c. PARROQUIA:

e. FAX:

f. E-mail:

7. ACTIVIDAD ECONMICA A LA CUAL SE DEDICA :

III. DATOS RELATIVOS A LA EMPRESA/INSTITUCIN/COOPERATIVA

1. DENOMINACIN O RAZN SOCIAL DE LA EMPRESA/INSTITUCIN/COOPERATIVA:
2. NMERO DEL RIF:

3. NMERO DEL NIT:

5.NMERO DEL IVSS:

4. NMERO DE TRABAJADORES:
6. NMERO DE ESTABLECIMIENTOS QUE POSEE LA EMPRESA:

7. DIRECCIN DE LA EMPRESA:
a. ESTADO:
c. TELFONO:

b. MUNICIPIO:

d. FAX:

e. E-MAIL:

8. ACTIVIDAD ECONMICA A LA CUAL SE DEDICA :

NOMBRE Y APELLIDO DEL DELEGADO(A) DE PREVENCIN:

NOMBRE Y APELLIDO DEL FUNCIONARIO:

CDULA DE IDENTIDAD:

CDULA DE IDENTIDAD:

FIRMA:

FECHA

FIRMA:

FECHA

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