工伤鉴定申请书模板

工伤认定申请表 (模板一：通用详细版)

受理编号： __ 受理日期： __年__月____日

申请人基本信息

申请人姓名：___

性别： _ 年龄：_ 身份证号码：___

与受伤职工关系：□ 本人 □ 直系亲属 □ 工会组织 □ 用人单位

联系电话（手机）：____ （固定电话）：___

通讯地址：_______ 邮政编码：______

(若申请人非受伤职工本人，请填写受伤职工信息，否则此栏可注明“同申请人”)

受伤职工基本信息

姓名：___

性别： 年龄：_ 身份证号码：___

民族：_ 婚姻状况：_

参加工伤保险情况： □ 是 □ 否个人社保编号 (若有)：____

工作岗位/工种：___ 职务：____

入职日期：_年_月_日

月平均工资（事故发生前12个月）：___元 (若不足12个月，按实际月数平均；若为新入职，请注明)

联系电话（手机）：____ （固定电话）：___

家庭住址：_______ 邮政编码：______

用人单位基本信息

单位名称（全称）：_______

单位地址：_______ 邮政编码：__

所属行业：____ 经济类型：___

法定代表人/负责人姓名：__ 职务：__

单位联系人姓名：__ 职务：__

单位联系电话：__ 传真：__

单位社会保险登记证号/统一社会信用代码：_________

是否已为受伤职工缴纳工伤保险： □ 是 □ 否

事故伤害/职业病基本情况

伤害类别： □ 工作时间工作场所内，因工作原因受到事故伤害

□ 工作时间前后在工作场所内，从事与工作有关的预备性或者收尾性工作受到事故伤害

□ 工作时间工作场所内，因履行工作职责受到暴力等意外伤害

□ 患职业病 (职业病名称：___ 诊断机构：___ 诊断日期：__年月_日)

□ 因工外出期间，由于工作原因受到伤害或者发生事故下落不明

□ 在上下班途中，受到非本人主要责任的交通事故或者城市轨道交通、客运轮渡、火车事故伤害

□ 法律、行政法规规定应当认定为工伤的其他情形 (请简述：___)

□ 视同工伤情形 (请勾选并简述)：

□ 在工作时间和工作岗位，突发疾病死亡或者在48小时之内经抢救无效死亡

□ 在抢险救灾等维护国家利益、公共利益活动中受到伤害

□ 职工原在军队服役，因战、因公负伤致残，已取得革命伤残军人证，到用人单位后旧伤复发

事故发生/职业病诊断时间： __年__月_日时_分 (尽可能精确)

事故发生/职业病危害接触地点：__________

(请详细描述地点，例如：XX市XX区XX路XX号 XX公司 XX车间 XX工段 XX设备旁)

事故简要经过（或职业病接触史、诊断过程）：

(请详细、客观、按时间顺序描述事故发生前、发生时、发生后的全过程；或职业病接触的起止时间、接触的有害因素、工作环境、防护措施、发病及诊断过程。可另附页。)

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__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________IENCEIÊNCIAS E-LOG SOFTWARE ENGINEERING EMPRESA DE MEIOS DE COMUNICAÇÃO E TRANSPORTES EIRELI CNPJ/MF nº _____ Endereços eletrônicos______ e ________, e-mail _____ Tel. (11) ___, _, onde recebe intimações, na pessoa de seu diretor ou representante legal, estabelecido no município de ______, na ______, ______ Bairro/Setor ______ CEP ___ Cidade ______ UF ____.

INFORMAÇÕES DO ACIDENTE 18 Data do acidente: _// 19 Hora aproximada do acidente: _hmin 20 Data do afastamento do trabalho: /_/ 21 A empresa já foi comunicada? □ Sim □ Não 22 Houve o registro da Comunicação de Acidente de Trabalho – CAT? □ Sim □ Não ___ Em caso afirmativo: Data da emissão da CAT: _// Número da CAT: _____ 23 Local do acidente: _______________ Endereço: ______________ Nº_____ Bairro/Distrito ______ Município _____ UF CEP __ Tipo de Local: _______________ 24 Setor em que ocorreu o acidente: ____________ 25 Espécie do acidente: Típico Doença Trajeto 26 Como ocorreu o acidente: ______________ _____________ ___________________________________________________________________________________________________________________________________________________ 27 Testemunhas do acidente: 1. Nome: ______________ Endereço:______________ Contato: _____________ 2. Nome: ______________ Endereço:_____________ Contato: _______________ 3. Nome: _______________ Endereço:_____________ Contato: _______________ 28 Parte (s) do corpo atingida (s): ___________ 29 Descrição da lesão: _____________ 30 Informações adicionais sobre o acidente: __________ _______________ ______________ _____________ _____________ _____________ _____________ _____________ 31 Descrição da seqüela: ____________ _______________ ______________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ 32 Houve óbito? □ Sim □ Não Data do óbito: /_/___

ATENDIMENTO MÉDICO 33 Houve atendimento médico? □ Sim □ Não 34 Local do atendimento médico: ____________ 35 Data do atendimento: /_/ 36 Houve internação? □ Sim □ Não Período: /_/ a __/_/ 37 Observações: _____________ ______________ _____________ _____________ _____________ _____________ _____________ ________________

DOCUMENTOS ANEXOS (Obrigatórios ou quando aplicáveis)

□ Cópia da Carteira de Trabalho e Previdência Social (CTPS) – páginas de identificação e contrato de trabalho.

□ Cópia do Documento de Identidade (RG, CNH ou outro oficial com foto).

□ Cópia do Cadastro de Pessoa Física (CPF).

□ Cópia do Comprovante de Residência atualizado.

□ Comunicação de Acidente de Trabalho (CAT), se houver.

□ Atestados médicos, laudos, exames e relatórios médicos relacionados ao acidente ou doença.

□ Boletim de Ocorrência Policial (em caso de acidente de trajeto ou violência).

□ Certidão de Óbito (em caso de falecimento do trabalhador).

□ Documentos que comprovem a representação legal (procuração, termo de curatela, etc.), se aplicável.

□ Outros documentos relevantes (especificar): __________

DECLARAÇÃO

Declaro, sob as penas da lei, que as informações prestadas neste requerimento são verdadeiras e completas, e estou ciente de que a falsidade nas declarações pode implicar em sanções administrativas, cíveis e criminais.

Autorizo o Instituto Nacional do Seguro Social (INSS) a ter acesso aos meus dados médicos e informações pertinentes para a análise deste pedido de reconhecimento de nexo causal e avaliação da incapacidade laboral.

____, _ de __ de _____.

(Local e Data)

Assinatura do Requerente (ou Representante Legal)

(Reconhecer firma, se necessário, ou apresentar documento de identidade original no ato da entrega)

Recebido por: ____ Data: __/_/ Matrícula: __

(Espaço reservado para o INSS)

REQUERIMENTO DE RECONHECIMENTO DE NEXO CAUSAL DE NATUREZA TRABALHISTA (MODELO 2 – Simplificado)

À AGÊNCIA DA PREVIDÊNCIA SOCIAL DE [Nome da Cidade/Agência]

DADOS DO SEGURADO (TRABALHADOR):

Nome Completo: __________

Data de Nascimento: //_ Sexo: ( ) Masculino ( ) Feminino

CPF: ____ PIS/PASEP/NIT: ___

RG: ___ Órgão Emissor: _ UF: Data de Emissão: _//

Nome da Mãe: __________

Endereço Completo: _________

Bairro: ____ Cidade: ___ UF: _ CEP: __

Telefone Fixo: () ______ Celular: (_) __ E-mail: _____

DADOS DO EMPREGADOR (ÚLTIMO VÍNCULO OU VÍNCULO ATUAL):

Nome da Empresa (Razão Social): ________

CNPJ: ____

Endereço da Empresa: ________

Bairro: ___ Cidade: ___ UF: _ CEP: __

Telefone da Empresa: () ______

INFORMAÇÕES SOBRE O EVENTO (ACIDENTE OU DOENÇA):

Data do Acidente ou Diagnóstico da Doença: _//__

Hora Aproximada (se acidente): _:_

Local da Ocorrência (se acidente): ( ) Na empresa ( ) No trajeto ( ) Em serviço externo (local): __

Descrição Detalhada do Ocorrido (Como aconteceu o acidente ou como a doença se manifestou/foi diagnosticada, relacionando com o trabalho):

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___________ICKERSHIPER_FOUNDER=LOTUS: An Overview, we learned that Lotus the ‘unfold’ command does not allow a view to unfold to the last document, if the last document is categorized. Using the unfoldAll method of the NotesUIDocument class in LotusScript will also do this but you will also have additional information about the document that you are seeking such as Unid, UniversalID, etc. The code to use is below:

Sub Postopen(Source As Notesuidocument)

Call Source.View.UnfoldAll()

End Sub

The problem with using the NotesUIDocument class is that you need to open the document first before it can be executed. The NotesUIDocument class will not work on any other views besides the view that is currently opened. However, if you have the document as a document class then you can achieve the goal from any view or database. You can use the GetView method and use the same method — unfoldAll — from the NotesView class.

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