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Unitatea medical: .

Adresa
Tel:Fax
Angajare _____ / Control medical periodic _____ / Adaptare _____ / Reluare a muncii _____/
special ____ / Altele _____.

Supraveghere

MEDICINA MUNCII FIA DE APTITUDINE NR. ______


( un exemplar se trimite la angajator, unul se nmneaz angajatului, unul rmne la unitatea medical)

Societate, unitate etc. _________________________________________________________________


Adresa _________________________________________________________________________________
Tel: _____________________________ Fax: __________________________________________________

NUME_____________________
PRENUME __________________________________CNP _________________________________________________________________
Profesie/funcie ____________________ Locul de munc ______________________

AVIZ MEDICAL:
APT
APT CONDIIONAT
INAPT TEMPORAR
INAPT

Recomandri ( unde este cazul):


_________________________________________________________________________

___________________________________________________
_______________________________________________________
Data ________________

Medic de medicina muncii


(semntura, parafa)

Unitatea medical: . Adresa


Tel:Fax
Angajare _____ / Control medical periodic _____ / Adaptare _____ / Reluare a muncii _____/
special ____ / Altele _____.

Supraveghere

MEDICINA MUNCII FIA DE APTITUDINE NR. ______


( un exemplar se trimite la angajator, unul se nmneaz angajatului, unul rmne la unitatea medical)

Societate, unitate etc. _________________________________________________________________


Adresa _________________________________________________________________________________
Tel: _____________________________ Fax: __________________________________________________

NUME_____________________
PRENUME __________________________________CNP _________________________________________________________________
Profesie/funcie ____________________ Locul de munc ______________________

AVIZ MEDICAL:
APT
APT CONDIIONAT
INAPT TEMPORAR
INAPT

Recomandri ( unde este cazul):


_________________________________________________________________________
________________________________________________________________________
__________________________________________________________________________

Data ________________

Medic de medicina muncii


(semntura, parafa)

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