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(pieczęć adresowa pracodawcy) (miejscowość i data)
PROTOKÓŁ przesłuchania poszkodowanego/świadka*
sporządzony w związku z wypadkiem z dnia...
(wypadek w drodze do lub z pracy)
Pan/Pani ................................................................ imię ojca ...................................... data urodzenia ........................................ miejsce urodzenia ...................................... zamieszkały(a): ul. ..................................................... nr domu/mieszkania ............... zatrudniony(a) ............................................................................................................. (nazwa zakładu pracy)
na stanowisku ..............................................................................................................
legitymujący(a) się dowodem osobistym: seria .............. nr .......................................(uprzedzony(a) o odpowiedzialności karnej z art. 233 Kodeksu karnego za składanie fałszywych zeznań lub zatajenie prawdy)* zeznaje co następuje:...............
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* Niepotrzebne skreślić
...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Na tym protokół zakończono i po odczytaniu zgodnie podpisano.
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(podpis i pieczęć prowadzącego przesłuchanie) (podpis przesłuchiwanego/ej)
2
ludwik72