OCCUPATIONAL MEDICINE

• Accelerated retirement plan

1. Identifying
2. Auditing
3. Tracking

• Identification and assessment of risks in the workplace and working environment
• Training in the organization of first aid, rescue, evacuation and handling of hazardous materials
• Analysis of injury, occupational diseases and diseases related to work

• Request - years of service at an accelerated rate

  Request - years of service at an accelerated rate

  I GENERAL INFORMATION
  1.	Requests submitter name:
  2.	Adress of requests submitter:
  3.	Phone:		Fax:
  4.	Company ID:		Tax ID:
  5.	Contact person:	Phone:	Fax:	E-mail:

  II OTHER INFORMATION
  1.	Company activity:
  2.	It is necessary to (check): Identifying the jobs to which years of service is calculated at an accelerated rate Audit jobs for which years of service account at an accelerated rate Identifying the jobs to which years of service calculated at an accelerated rate through the protocole of the employer
  3.	Do you own the record for identifying the jobs to which years of service is calculated at an accelerated rate? YES NO
  4.	Number of jobs that will be subject to determination / review:
  NOTE: Upon accepting the offer the following documents must be submitted: 1. Normative acts and record of companies statute; Regulation on organization and systematization; organizational chart; job descriptions; collective bargaining agreement (Ordinance on Occupational Safety and Health) with a list of personal protective equipment; personnel records on allocation of workers to jobs; medical records of periodic examinations of workers, the last 10 years (for all workers who worked at that time on the observed positions): name of workers, job title, educational level and profession; year of birth; total years of work (years); years of service on the analyzed workplace (exposure years of service); data on chronic morbidity: disease diagnosis or passwords with reports of periodic reviews, expertise and so on. If the reports with periodic reviews are not written diagnosis, please allow access to medical records of occupational health services; number of workers employed (currently) on analyzed workplace. injury lists, last 10 years (for all workers who worked at that time on the observed positions): diagnosis, or code of injury with the causes of injuries and number of days lost on that basis; list of workers suffering from occupational diseases, the last 10 years (for workers on the observed positions) list of survivors (victims) of workers in the observed positions, the last 10 years (with cause of death); list of disabled workers with the correct name of the job at which the disability occurred, the year the disability occurred and cause of disability (illness, occupational disease, injuries or injuries outside of work) number of sick days, as a result of disease or injuries caused in the workplace, the last 10 years (for workers on the observed positions) 2. 1. Technological process detailed description of the technological process; description of the technological process for reporting workplace; opinion on possible technical - technological modernization of work processes and protective measures; list of equipment, tools and objects of the observed workplace (Subject matter: raw materials and other materials, the work equipment, machinery, tools, etc..); list of dangerous (fire, explosion, injury, etc..), and hazards (chemical, biological and physical) with whom the worker have contact in the workplace; plan based of company with marked objects in which assessed workplaces appear radna mesta; information from technical documentation (operating list, a list of operations, a list of tools); the latest test results of working environment; protocoles from the last inspection of equipment (machinery and equipment, installations, internal transport, etc..).

  III THE PERSON DATA WHO COMPLETED THE APPLICATION
  1.	Name, surname and function:
  2.	Mobile:	Phone:	Fax:
  3.	E-mail:
  4.	Date of filling the request:
  	Image code: