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
(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 _____________________________________
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
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)