MANIFESTACION DEL ACCIDENTE

1. DIGA UD., SU NOMBRE COMPLETO Y OCUPACION.

Nombres y Apellidos:
DNI.:
Cargo:

2. ¿TIENE ORDEN DE TRABAJO?, explique.

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3. ¿CUANTO TIEMPO TIENE LABORANDO EN LA EMPRESA?

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4. ¿PARTICIPÓ EN LA REUNIÓN DIARIA DE CINCO MINUTOS ANTES DEL INICIO DE LA

JORNADA?
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5. ¿DONDE SE ENCONTRABA UD. A LA HORA DEL EVENTO?

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6. AL MOMENTO DEL ACCIDENTE, RELATE QUE ACTIVIDAD SE ENCONTRABA REALIZANDO

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7. RELATE COMO SUCEDIÓ EL ACCIDENTE.
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8. ¿PORQUE CREE UD QUE OCURRIO EL ACCIDENTE?

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9. ¿CREE QUE SE PUDO EVITAR, Y COMO?

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10. ¿ALGO MAS QUE DESEE ACOTAR?

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NOMBRE:
DNI: