Anexa nr.

2
la Regulamentul privind
modul de cercetare a accidentelor
de muncă
MINISTERUL ECONIMIEI ŞI COMERŢULUI МИНИСТЕРСТВО ЭКОНОМИКИ И ТОРГОВЛИ

AL REPUBLICII MOLDOVA РЕСПУБЛИКИ МОЛДОВА

INSPECŢIA MUNCII ИНСПЕКЦИЯ ТРУДА

INSPECTORATUL TERITORIAL DE MUNCĂ ТЕРИТОРИАЛЬНАЯ ИНСПЕКЦИЯ ТРУДА
__________________________________________ _________________________________________

PROCES - VERBAL nr.

privind cercetarea accidentului de muncă ______________
(tipul)

1. Denumirea unităţii (numele, prenumele, patronimicul angajatorului persoană fizică) în care

(la care) s-a produs accidentul _____________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
1.1 Adresa unităţii (angajatorului persoană fizică)_____________________________________
______________________________________________________________________________
______________________________________________________________________________
1.2 Forul superior ____________________________________________________________
1.3 Activitatea economică ______________________________________________________
______________________________________________________________________________
1.4 Forma de proprietate________________________________________________________
(publică, privată )

1.5 Codul fiscal/IDNO sau IDNP_________________________ Certificatul de înregistrare:

seria_____ nr. _______________ eliberat la „_____” ____________________ 200_

1.6 Numărul de angajaţi la unitate (angajator persoană fizică) _______ inclusiv_____ femei
1.7 Secţia, sectorul, locul unde s-a produs accidentul__________________________________
20. Denumirea unităţii (numele, prenumele, patronimicul angajatorului persoană fizică) al
cărei (cărui) a fost / este accidentatul ________________________________________________
______________________________________________________________________________
2.1 Adresa unităţii (numele, prenumele, patronimicul angajatorului persoană fizică)_________
______________________________________________________________________________
______________________________________________________________________________
3. Datele de identificare ale accidentatului:
3.1 Numele, prenumele, patronimicul_____________________________________________
______________________________________________________________________________
3.2 Adresa la domiciliu________________________________________________________
______________________________________________________________________________
3.3 Sexul ___________________________________________________________________
(masculin, feminin)

3.4 Vîrsta (ani compleţi) _______________________________________________________

3.5 Funcţia, profesia, meseria ___________________________________________________
______________________________________________________________________________
3.6 Vechimea în funcţia, profesia, meseria exercitată în timpul accidentării _______________
3.7 Instruirea în domeniul protecţiei muncii ________________________________________
(data , nu s-a efectuat, nu este necesr)

3.7.1 Instruirea suplimentară în domeniul protecţiei muncii______________________________

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

3.7.2 Instructajul la locul de muncă sau periodic______________________________________

(data, nu s-a efectuat)

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3.8 Controlul medical
3.8.1 Controlul medical la încadrare în muncă________________________________________
(data, nu s-a efectuat)

______________________________________________________________________________

3.8.2 Controlul medical periodic___________________________________________________

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

4. Data şi ora producerii accidentului____________________________________________

5. Clasificarea accidentului_____________________________________________________
(individual, colectiv)

6. Descrierea detaliată a locului şi a circumstanţelor în care s-a produs accidentul__________

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6.1 Clasificarea circumstanţelor care au condus la producerea accidentului________________
______________________________________________________________________________
(cădere, prindere, lovire, strivire, explozii, incendii, atac criminal, contact cu curent electric etc.)

7. Cauzele producerii accidentului dependente de:

7.1 executant________________________________________________________________
(încălcarea disciplinei de muncă şi a instrucţiunilor, nefolosirea echipamentului de protecţie etc.)

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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7.2 mijloace de producţie______________________________________________________
(defecte sau imperfecţiuni ale utilajului, starea tehnică a clădirilor şi a drumurilor)

______________________________________________________________________________
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______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________

7.3 sarcina de muncă___________________________________________________________

(lacune în organizarea locurilor de muncă şi a lucrărilor, lacune în instruirea personalului etc.)

______________________________________________________________________________
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7.4 mediul de muncă___________________________________________________________

(concentraţia prafului şi a gazului, temperatura, umiditatea aerului, nivelul de iluminare etc.)

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Diagnoza vătămării organismului___________________________________________________
______________________________________________________________________________
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______________________________________________________________________________

2
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(se transcrie din certificatul eliberat de instituţia medicală)

8. Persoanele care au încălcat prevederile actelor legislative şi altor acte normative din
domeniul muncii ________________________________________________________________
(numele, prenumele, articolele încălcate din actele normative)

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

9. Măsuri de lichidare a cauzelor de producere a accidentului şi de prevenire a unor

evenimente similare:

Nr.d/ Termen de Responsabil

Denumirea măsurilor Note
o realizare de realizare

Procesul-verbal a fost întocmit la „______”____________________200_ de către

inspectorul de muncă ___________________________ _______________

(numele, prenumele) (semnătura)

La cercetare au participat
_______________________________ _____________________________ _______________
(funcţia) (numele, prenumele) (semnătura)

_______________________________ _____________________________ _______________

(funcţia) (numele, prenumele) (semnătura)

_______________________________ _____________________________ _______________

(funcţia) (numele, prenumele) (semnătura)

_______________________________ _____________________________ _______________

(funcţia) (numele, prenumele) (semnătura)

_______________________________ _____________________________ _______________

(funcţia) (numele, prenumele) (semnătura)

_______________________________ _____________________________ _______________

(funcţia) (numele, prenumele) (semnătura)