CABINET INDIVIDUAL DE PSIHOLOGIE

Nr.______din data________

COD ________________

DOSAR DE EXAMINARE MUNC

NUMELE I PRENUMELE______________________________data naterii_________
CNP______________________________________________________________________
FUNCIA_______________________________UNITATEA_______________________
DATA EXAMINRII____________________MOTIVUL_________________________

DECLARAIE
Declar pe proprie rspundere c sunt odihnit, nu simt
nici-o durere fizic, nu am consumat buturi alcoolice n
cursul zilei de azi, nainte de prezentarea mea la examen, nu
am fost internat n spital la neurologie sau psihiatrie.
De asemenea, nu am probleme de vedere la acest moment.
Semnez aceast declaraie cunoscnd toate consecinele unei
declaraii neadevrate.
Semntura_____________BI/CI seria_______nr_______
Ultimul examen psihologic____________________________
AVIZUL_______________________

SEMNTURA I PARAFA PSIHOLOG

ANAMNEZA

NUME I PRENUME_______________________________________vrsta____________
CNP_______________________________
DOMICILIUL______________________________________________________________
STAREA CIVIL___________________________________________________________
Cu copii___________________________________________________________________
Denumirea postului de munc__________________________________________________
Societatea angajatoare________________________________________________________
1.Scopul examinrii (ncercuii litera corespunztoare)
a) angajare
b)examen periodic
c) altele

2. ! Numai pentru angajaii care lucreaz la nlime ( peste 2 m):

Subliniai strile pe care recunoatei c le avei frecvent cnd lucrai la nlime:
a) respiraie accelerat, nod n gt, palpitaii, ameeli, tremor al picioarelor, grea, amoreli,
valuri de cldur sau frig, dureri sau disconfort n zona pieptului, teama de a nu pierde
controlul, teama de moarte, altele_______________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
b) Nu am niciuna din strile de la punctul a.

Declar pe proprie rspundere c sunt apt pentru a lucra la nlime i m

angajez s respect normele de protecie a muncii n condiiile de lucru la
nlime,conform prevederilor n vigoare.
SEMNTURA_________________

3. ! Numai pentru angajaii care lucreaz sub tensiune ( curent electric):

Declar pe propria rspundere c n timpul activitilor de munc ce

implic lucru sub tensiune,respect n totalitate normele de protecia a muncii
n vigoare.
SEMNTURA_______________
4STUDII: ( ncercuii litera corespunztoare)
a) clase n coala general
b) Profesionale..
c) c) liceale:clase; cu bacalaureat DA/NU ( ncercuii da sau nu)
d) superioare.
5.EVOLUIA PROFESIONAL
Nr
crt
1

Postul de munc Firma

ocupat
angajatoare

Durata n timp
aproximativ

Cu/fr carte de
munc/contract

2
3
4
5

6.MEDIUL SOCIAL DIN CARE PROVINE:

Profesia prinilor: Mam________________________Tat_____________________
Situaia familiar a prinilor________________________________________________
Frai i surori____________________________________________________________

7.MEDIUL SOCIAL ACTUAL:

Familia ( cstorit, necstorit)_________________
Condiiile de via :
A) mai puin bune
B) bune
C) foarte bune
6. DATE ASUPRA ACTIVITII PROFESIONALE
Ce factori de stres ai ntmpinat n serviciile anterioare?
a) programul____________________________________________________________
b) b) condiiile de munc___________________________________________________
c) relaiile cu colegii______________________________________________________
d) relaia cu efii_________________________________________________________
e) salariul_______________________________________________________________
f) altele________________________________________________________________
7. N TIMPUL SERVICIILOR ANTERIOARE,AI FOST IMPLICAT VREODAT
NTR-UN ACCIDENT DE MUNC?
DA_________NU___________
Dac da, completai:
n ce an________________
Locul de munc pe care l ocupai la data producerii incidentului____________________
Care au fost cauzele_______________________________________________________
Care au fost urmrile______________________________________________________

REFERAT
NUMELE I PRENUMELE___________________________________________________
VRSTA__________________________________________________________________
VECHIMEA PROFESIONAL________________________________________________
AVIZUL ULTIMULUI EXAMEN PSIHOLOGIC_________________________________
MOTIVUL EXAMINRII____________________________________________________

INTERPRETAREA REZULTATELOR I
PROFILUL PSIHOLOGIC OBINUT
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

AVIZ:________________________________________________
DATA EXAMINRII___________________________________

PSIHOLOG EXAMINATOR