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.
Документы, которые обычно оформляют в том же процессе.
Record of hazards and risk assessment for a workplace or type of work using the selected method. Records the initial assessment separately from the actual reassessment after measures have been implem…
Employer's report on identified hazards, assessment results and risk reduction measures. Completed using the survey findings and the approved method.
Employer's plan to reduce occupational risks and improve working conditions, specifying persons responsible, deadlines, a budget and result monitoring. Measures are selected on the basis of the actua…
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