O‘zbekiston respublikasi sog‘liqni saqlash vazirining

Mastlik holati bo‘yicha mehnatga layoqatsizlik
MA’LUMOTNOMASI

20___ yil “___” _____________				___________-son
Familiyasi, ismi_________________________________________________________ Yoshi _______________________ Jinsi ______________________________________ Ish joyi _______________________________________________________________
	(tashkilot nomi)
Tashxis _________________________________________________________________ Yakuniy tashxis ___________________________________________________________ Layoqatsizlik turi _________________________________________________
	(kasallik, ishlab chiqarishdagi, turmushdagi baxtsiz hodisalar)
Tartib _________________________________________________________________
	(ambulator yoki statsionar)
Shifoxonada bo‘lgan davri			20___ yil “_____” __________________ 20___ yil “_____” ________________dan 20___ yil “_____” _______________ gacha
TIEKga yo‘llangan sana			20___ yil “_____” _________________
Shifokorning imzosi			__________
TIEK ko‘rigidan o‘tgan sana			20___ yil “_____” ___________________
TIEK xulosasi			__________
Vaqtincha boshqa ishga o‘tkazilsin			20___ yil “_____” _______________ dan 20___ yil “_____” _______________ gacha
Bosh shifokor imzosi			__________
TIEK raisining imzosi va TIEK muhri			__________
Ishdan ozod etilgan kunlar (shu kunlar bilan birga)			20___ yil “_____” _______________ dan 20___ yil “_____” _______________ gacha
Shifokorning F.I.O.			______________________________
Shifokorning imzosi			__________
Ishga tushish sanasi (so‘z bilan yoziladi)			______________________________
Yangi ma’lumotnoma berildi			20___ yil “_____” _________________ da
			___________-son
Davolash-profilaktika muassasasi muhri

(2-ilova O‘zbekiston Respublikasi sog‘liqni saqlash vazirining 2021-yil 2-iyuldagi 9-sonli buyrug‘i (ro‘yxat raqami 2667-3, 15.07.2021-y.) tahririda — Qonunchilik ma’lumotlari milliy bazasi, 15.07.2021-y., 10/21/2667-3/0675-son)
Mehnatga layoqatsizlik varaqalarini berish tartibi to‘g‘risidagi yo‘riqnomaga
3-ILOVA

(Muassasa shtampi)					095\x shakl
Ta’lim olayotgan shaxslar uchun mehnatga layoqatsizlik MA’LUMOTNOMASI
20___ yil “___” _____________				___________-son
Familiyasi, ismi ________________________________________________________
Yoshi ________________________ Jinsi _____________________________________
O‘qish joyi______________________________________________________________
	(tashkilot nomi)
Tashxis_________________________________________________________________
Yuqumli kasallikka chalingan bemor bilan kontaktda bo‘lganligi haqidagi ma’lumotlar ________________________________________________________________________
O‘quv mashg‘ulotlaridan ozod etilgan kunlar (shu kunlar bilan birga)			20___ yil “_____” _______________ dan 20___ yil “_____” _______________ gacha
Shifokorning F.I.O.			_____________________________
Shifokorning imzosi			_________
Yangi ma’lumotnoma berildi			�20___ yil “_____” _________________ da ___________-son
Davolash-profilaktika muassasasi muhri

Mehnatga layoqatsizlik varaqalarini berish tartibi to‘g‘risidagi yo‘riqnomaga
4-ILOVA

(Muassasa shtampi)								138\x shakl
Bemor bolani parvarishlash uchun mehnatga layoqatsizlik MA’LUMOTNOMASI
20___ yil “___” ____________							___________-son
Bemor bola haqidagi ma’lumotlar:
Familiyasi, ismi, otasining ismi ___________________________________________
Yoshi _______________________ Jinsi ______________________________________
O‘qish joyi ______________________________________________________________
	(tashkilot nomi)
Tashxis__________________________________________________________________
Parvarish qiluvchi haqidagi ma’lumotlar: _____________________________________
Familiyasi, ismi, otasining ismi____________________________________________
Qarindoshligi __________________________ Jinsi ___________________________
Ish joyi ________________________________________________________________
	(tashkilot nomi)
Ishdan ozod etilgan kunlar:
Qaysi vaqtdan (yil, sana, oy) (so‘z bilan)		Qaysi vaqtgacha (yil, sana, oy) (so‘z bilan)		Shifokorning lavozimi, familiyasi		Shifokorning imzosi		Vrachlik maslahat komissiyasi raisining imzosi
Yangi ma’lumotnoma berildi					20___ yil “____” _________________ da ___________-son
Davolash-profilaktika muassasasi muhri

(O‘zbekiston Respublikasi qonun hujjatlari to‘plami, 2015-y., 15-son, 194-modda; Qonun hujjatlari ma’lumotlari milliy bazasi, 25.12.2019-y., 10/19/2667-1/4230-son; 15.06.2020-y., 10/20/2667-2/0765-son; Qonunchilik ma’lumotlari milliy bazasi, 15.07.2021-y., 10/21/2667-3/0675-son, 28.07.2021-y., 10/21/3313/0724-son)