Had It A

  • October 2019
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‫›› تصريح بحادثة مدرسية ‹‹‬ ‫(التلميذ(ة) المصاب‬

‫(ة‬

‫‪: ....................................‬المؤسسة‬ ‫‪: ...............................................................................‬السم والنسب‬ ‫‪: .............................‬رقم التسجيل‬ ‫‪: ....................................................‬القسم‬ ‫‪: ...................................................................................................... ...............................................‬العنوان‬ ‫‪:‬المكلف(ة) بالحراسة‬ ‫‪: ................‬رقم التأجير‬

‫‪(: .............................‬بصفته(ا‬ ‫‪(: ...................................................‬السيد(ة‬ ‫‪:‬يصرح للسيد(ة) المدير(ة) أن الحادثة وقعت يوم‬ ‫‪: ......................................................................‬بالمكان التالي‬ ‫‪: ................‬على الساعة‬ ‫‪: ...........................................................................................................‬ظروف الحادث‬ ‫‪................................................................................................................................‬‬ ‫‪................................................................................................................................‬‬ ‫‪.................................................................................................................................‬‬ ‫‪:‬إمضاء المكلف(ة) بالحراسة‬ ‫‪:‬شهود الحادث‬ ‫‪: ....................................................‬السم والنسب ‪: ................ 1-‬رقم التسجيل ‪: ................‬القسم‬ ‫‪: .....................................................................................................................‬شهادته‬ ‫‪................................................................................................................................‬‬ ‫‪................................................................................................................................‬‬ ‫‪:‬المضاء‬ ‫‪: ....................................................‬السم والنسب ‪: ................ 1-‬رقم التسجيل ‪: ................‬القسم‬ ‫‪: .....................................................................................................................‬شهادته‬ ‫‪................................................................................................................................‬‬ ‫‪................................................................................................................................‬‬ ‫‪:‬المضاء‬ ‫‪: ....................................................‬السم والنسب ‪: ................ 1-‬رقم التسجيل ‪: ................‬القسم‬ ‫‪: .....................................................................................................................‬شهادته‬ ‫‪................................................................................................................................‬‬ ‫‪................................................................................................................................‬‬ ‫‪:‬المضاء‬ ‫‪:‬تقرير رئيس(ة) المؤسسة‬ ‫‪...............................................................................................................................‬‬ ‫‪................................................................................................................................‬‬ ‫‪................................................................................................................................‬‬ ‫‪.................................................................................................................................‬‬ ‫‪...............................................................................................................................‬‬ ‫‪: ............. ................ ...................‬حرر في‬ ‫‪:‬إمضاء رئيس(ة) المؤسسة‬

‫‪: ................ ................‬بتاريخ‬

‫‪.‬يرفق التقرير بتصميم يبين مكان وقوع الحادث وموقع المكلف بالحراسة‬

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