Download Allegati A - B - C - D

Mod. RI/ISL/IMP
Data emissione: 1/2/2008
Data aggiornamento: 01/07/10
SICUREZZA - SPP
No progressivo /Anno ________/________
(a cura Sicurezza – SPP)
RAPPORTO DI INFORTUNIO SUL LAVORO – IMPRESA
NB: il presente modulo deve pervenire, opportunamente compilato dall’impresa, alla Direzione Lavori nel più breve tempo possibile
DATI IMPRESA
Impresa appaltatrice: __________________________________________________________________________________________________
per i lavori di _________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Impresa subappaltarice: _______________________________________ (impresa appaltatrice _______________________________________)
Per i lavori di _________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
DATI INFORTUNATO
Mansione ________________________________________________________ Giorni Prognosi (se nota) ______________________________
Mansione ________________________________________________________ Giorni Prognosi (se nota) ______________________________
Mansione ________________________________________________________ Giorni Prognosi (se nota) ______________________________
A CURA DELL’IMPRESA
DESCRIZIONE DELL’ INFORTUNIO
Luogo dell’infortunio ___________________________________________________________________________________________________
(Viia/piazza, n. civico, Comune, prov., cap)
___________________________________________________________data dell’infortunio ________________________ ora _____________
Attività o servizio svolto al momento dell’infortunio
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Descrizione particolareggiata dell’infortunio
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Data: ____________________
Firma: _____________________________
DIREZIONE LAVORI
A CURA DIREZIONE LAVORI
Direttore Lavori (Cognome e Nome) _________________________________
Unità Organizzativa: _____________________________________________________ Società__________________________________________
Eventuali note/osservazioni: _____________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Viene Inviata copia a Sicurezza – SPP.
Data: ____________________
Firma Direttore Lavori: _________________________
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