REABILITAREA, RESTAURAREA SI VALORIFICAREA

S.C. HESTER-ART S.R.L. TURISTICA DURABILA A BISERICII “ SF. PANTELIMON “ , PROIECT 2020
comuna VEDEA, judetul GIURGIU

Rev 0 REGISTRUL JURNAL DE COORDONARE ANEXA 14

Raport de eveniment (accident)

1. Numele si prenulele persoanei accidentate :_____________________________________________________________

2. Sex ( M / F ): ____________________________________________________________________________________
3. Data nasterii: ____________________________________________________________________________________
4. Ocupatia / calificarea :_____________________________________________________________________________
5. Cetatenia : ______________________________________________________________________________________
6. Act identitate (Nr. CI sau Pasaport ): __________________________________________________________________
7. Numele angajatorului : _____________________________________________________________________________
8. Ocupatia in momentul accidentului : ___________________________________________________________________
9. Experienta in meserie: __________ (luni / ani)
10. Data si ora accidentului: ____________________________________________________________________________
11. Locul accidentului : ________________________________________________________________________________
12. Leziuni suferite : __________________________________________________________________________________
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13. Numarul de zile estimate pentru ingrijire / grad de invaliditate estimat: ________________________________________
14. Accidentatul a primit Primul ajutor in santier (DA/NU)______________________________________________________
15. Spitalul unde a fost transportata victima:(Nume)__________________________________________________________

16. Scurta declaratie a sefului direct

Schita (poza):

1
 REABILITAREA, RESTAURAREA SI VALORIFICAREA
S.C. HESTER-ART S.R.L. TURISTICA DURABILA A BISERICII “ SF. PANTELIMON “ , PROIECT 2020
comuna VEDEA, judetul GIURGIU

Rev 0 REGISTRUL JURNAL DE COORDONARE ANEXA 14

17. Cauzele accidentului / incidentului (pe scurt, concluzia Persoanei cu atributii pe linie de SSM)
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18. Masuri imediate pentru a se evita evenimente similare (pe scurt, concluzia Persoanei cu atributii pe linie de SSM)
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19. Cine intocmeste toate demersurile si documentele legale aferente accidentului:

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Intocmit: Data: ____________

(Nume, semnatura)
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20. Comentarii ale Managerului de proiect / Sefului de santier :

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Semnatura: _______________ Data: ___________