Fillable structure of Form No. 2, N-1 (Н-1), under Order No. 223n (223н), retaining the sections and classification codes. For an ordinary occupational accident that has been investigated, rather than the special forms N-1PS (Н-1ПС) and N-1S (Н-1С).
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Form No. 2. Form N-1 (Н-1)
APPROVED BY __________ / / Approval date: . Seal, if any.
Date prepared: . Code 3.01: .
Date: . 1.1. Local time: . Code 3.02: . 1.2. Full hours since the start of work: . Code 3.03: .
. Address: . Taxpayer identification number (ИНН) . Departmental and industry affiliation: . Russian Classification of Economic Activities (ОКВЭД) code . Code 3.04: . Number of employees . Structural department: .
The employee was not sent by another organization (individual).
| Full name | Position | Place of work | Role / participation |
Additional information on membership:
5.1. Surname, first name, patronymic: . 5.2. Sex: male. Code 3.05: . 5.3. Date of birth: . Code 3.06: . 5.4. Professional status: . Code 3.12: . 5.5. Employment status: . Code 3.13: . 5.6. Occupation (position): . Code 3.14: . 5.7. Experience in the work during which the accident occurred: . Code 3.07: . Including service with this organization: . 5.8. Marital status and family composition (full names and ages of dependent family members): .
6.1. Induction safety briefing: conducted on . 6.2. Workplace safety briefing for the occupation/work : initial, date . 6.3. Supervised on-the-job training: conducted from to . 6.4. Occupational safety and health training for the occupation/work during which the accident occurred: conducted from to . 6.5. Knowledge assessment for the relevant occupation/work: .
7.1. Medical examination: Periodic examination, date . 7.2. Psychiatric examination: completed on . 7.3. Pre-shift (pre-flight) medical examination: Pre-shift examination completed on .
8.1. Location, address and brief description: . 8.2. Hazardous and harmful workplace factors, with reference to the site inspection record: . 8.3. Equipment whose use led to the accident (name, type, model, year of manufacture, manufacturer; state if none): . 8.4. Special assessment of working conditions (СОУТ): workplace No. , class (subclass) . Code 3.08: . 8.5. Organization that conducted the special assessment of working conditions: , taxpayer identification number . 8.6. Occupational risk assessment: date , internal instrument and results ; acknowledgment by the injured person . 8.7. Issue and receipt of personal protective equipment (PPE; СИЗ) by the injured person: .
9.1. Type of incident: . Code 1: . 9.2. Nature of injuries and injured organ: . Medical opinion on severity and its details: . International Classification of Diseases (ICD; МКБ) code . Code 3.01: . 9.3. Intoxication: none; evidence supporting the finding . 9.4. Eyewitnesses (full name, permanent residence, telephone, email address; state if none): .
Primary cause: . Code 2: . Contributing causes: . Codes 2: . Requirements of legislation, other regulatory legal instruments and internal policies that were breached, with exact references and provisions: .
Employers of these persons (name, address, full name of any employer who is an individual): . Gross negligence by the injured person has not been established; no degree of fault is determined.
| No. | Measure | Completion deadline | Person responsible |
Additional measures:
Signatures of the persons who conducted the investigation (personal signature, surname, initials, date):
Details of delivery (dispatch) of the report to the injured person, legal representative or authorized representative:
This is a blank template. Before use, have a lawyer review the text and adapt it to current legislation and the specific situation. This document is not legal advice.
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