̲ͲÑÒÅÐÑÒÂÎ ÎÕÎÐÎÍÈ ÇÄÎÐÎÂ'ß ÓÊÐÀ¯ÍÈ
ÍÀÊÀÇ
â³ä 19 òðàâíÿ 2003 ðîêó N 224
²ç çì³íàìè ³ äîïîâíåííÿìè, âíåñåíèìè
íàêàçîì ̳í³ñòåðñòâà îõîðîíè çäîðîâ'ÿ Óêðà¿íè
â³ä 8 æîâòíÿ 2007 ðîêó N 623
 çâ'ÿçêó ç ïåðåõîäîì çàêëàä³â îõîðîíè çäîðîâ'ÿ íà ì³æíàðîäíó ñòàòèñòè÷íó êëàñèô³êàö³þ õâîðîá äåñÿòîãî ïåðåãëÿäó (ÌÊÕ) òà ç ìåòîþ âäîñêîíàëåííÿ îáë³êîâî¿ äîêóìåíòàö³¿, ùî âèêîðèñòîâóºòüñÿ â ìåäèêî-ñîö³àëüíèõ åêñïåðòíèõ êîì³ñ³ÿõ íàêàçóþ:
1. Çàòâåðäèòè ôîðìè îáë³êîâî¿ äîêóìåíòàö³¿, ùî âèêîðèñòîâóþòüñÿ â ä³ÿëüíîñò³ ìåäèêî-ñîö³àëüíèõ åêñïåðòíèõ êîì³ñ³é:
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- ôîðìà N 156/î |
Àêò îãëÿäó ÌÑÅÊ ïî âèçíà÷åííþ ìåäè÷íèõ ïîêàçàíü äëÿ çàáåçïå÷åííÿ ³íâàë³ä³â àâòîìîá³ëÿìè |
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- ôîðìà N 156-1/î |
Âèïèñêà ³ç àêòà îãëÿäó ÌÑÅÊ ïî âèçíà÷åííþ ìåäè÷íèõ ïîêàçàíü äëÿ çàáåçïå÷åííÿ ³íâàë³ä³â àâòîìîá³ëÿìè |
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- ôîðìà N 156-2/î |
Äîâ³äêà ïðî ðåçóëüòàòè îãëÿäó íà âñòàíîâëåííÿ ìåäè÷íèõ ïîêàçàíü äëÿ çàáåçïå÷åííÿ ³íâàë³äà àâòîìîá³ëåì |
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- ôîðìà N 156-3/î |
Æóðíàë ïðîòîêîë³â çàñ³äàíü ÌÑÅÊ ïî àâòîòðàíñïîðòó |
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- ôîðìà N 157/î |
Àêò îãëÿäó ÌÑÅÊ |
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- ôîðìà N 157-1/î |
Âèïèñêà ³ç àêòà îãëÿäó ÌÑÅÊ |
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- ôîðìà N 157-2/î |
Âèñíîâîê ïðî ÷àñ íàñòàííÿ ³íâàë³äíîñò³ |
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- ôîðìà N 157-3/î |
Äîâ³äêà äëÿ íàïðàâëåííÿ â áóäèíîê-³íòåðíàò |
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- ôîðìà N 157-4/î |
Æóðíàë îáë³êó äîâ³äîê ÌÑÅÊ (ñóâîðî¿ çâ³òíîñò³), âèäàíèõ ³íâàë³äàì |
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- ôîðìà N 157-5/î |
Æóðíàë ïðîòîêîë³â çàñ³äàíü ÌÑÅÊ |
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- ôîðìà N 158/î |
Äîâ³äêà ïðî ðåçóëüòàòè âèçíà÷åííÿ ñòóïåíÿ âòðàòè ïðîôåñ³éíî¿ ïðàöåçäàòíîñò³ ó â³äñîòêàõ çàñòðàõîâàíîãî |
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- ôîðìà N 158-1/î |
Âèïèñêà ³ç àêòà îãëÿäó ÌÑÅÊ ïðî ðåçóëüòàòè âèçíà÷åííÿ âòðàòè ïðîôåñ³éíî¿ ïðàöåçäàòíîñò³ ó â³äñîòêàõ, ïîòðåáè ó äîäàòêîâèõ âèäàõ äîïîìîãè |
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- ôîðìà N 158-2/î |
Âèïèñêà ç àêòà îãëÿäó ÌÑÅÊ |
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- ôîðìà N 159/î |
Ñòàòèñòè÷íèé òàëîí |
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- ôîðìà N 159-1/î |
Ñòàòèñòè÷íèé òàëîí N 2 |
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- ôîðìà N 160-1/î |
Æóðíàë îáë³êó ³íäèâ³äóàëüíèõ ïðîãðàì ðåàá³ë³òàö³¿ ³íâàë³ä³â ÌÑÅÊ |
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- ôîðìà N 160-2/î |
Æóðíàë îáë³êó îòðèìàííÿ ³ âèòðàò äîâ³äîê ÌÑÅÊ |
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- ôîðìà N 160-3/î |
Ìåäåêñïåðòíà ñïðàâà |
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- ôîðìà N 160-4/î |
Æóðíàë êîíòðîëþ âèêîíàííÿ ³íäèâ³äóàëüíèõ ïðîãðàì ðåàá³ë³òàö³¿ ³íâàë³ä³â |
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- ôîðìà N 161/î |
Íàïðàâëåííÿ ³íâàë³äà â ë³êóâàëüíî-ïðîô³ëàêòè÷í³ çàêëàäè òà â ³íø³ îðãàíè ³ óñòàíîâè |
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- ôîðìà N 162/î |
Ïîâ³äîìëåííÿ ï³äïðèºìñòâó, óñòàíîâ³, îðãàí³çàö³¿ ïðî ðåçóëüòàòè îãëÿäó ÌÑÅÊ |
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- ôîðìà N 163/î |
Æóðíàë îáë³êó ìåäèêî-ñîö³àëüíèõ åêñïåðòíèõ ñïðàâ, ùî íàäõîäÿòü â îáëàñíó ÌÑÅÊ |
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- ôîðìà N 163-1/î |
Æóðíàë îáë³êó ïåðåäà÷³ ìåäèêî-ñîö³àëüíèõ åêñïåðòíèõ ñïðàâ |
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- ôîðìà N 164/î |
Æóðíàë îáë³êó êîíñóëüòàö³é ÌÑÅÊ |
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- ôîðìà N 164-1/î |
Æóðíàë îáë³êó íàïðàâëåíü â íàóêîâî-äîñë³äí³ ³íñòèòóòè ÌÑÅ |
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- ôîðìà N 164-2/î |
Æóðíàë ðåºñòðàö³¿ çâåðíåíü ãðîìàäÿí |
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- ôîðìà N 165/î |
Æóðíàë îáë³êó íàïðàâëåíü íà ÌÑÅÊ |
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- ôîðìà N 166/î |
Æóðíàë îáë³êó ïðîäîâæåííÿ ë³êóâàííÿ ïî ëèñòêó òèì÷àñîâî¿ íåïðàöåçäàòíîñò³ |
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- ôîðìà N 167/î |
Äîâ³äêà ïðî íåâèçíàííÿ ³íâàë³äîì. |
(ïóíêò 1 ³ç çì³íàìè, âíåñåíèìè çã³äíî ç íàêàçîì
̳í³ñòåðñòâà îõîðîíè çäîðîâ'ÿ Óêðà¿íè â³ä 08.10.2007 ð. N 623)
2. Ââàæàòè òàêîþ, ùî íå çàñòîñîâóºòüñÿ íà òåðèòî𳿠Óêðà¿íè, ²íñòðóêö³þ ïî âåäåííþ ä³ëîâîäñòâà ó ËÒÅÊ, çàòâåðäæåíó ïîñòàíîâîþ Äåðæàâíîãî êîì³òåòó ÑÐÑÐ â³ä 05.08.85.
3. ̳í³ñòðó îõîðîíè çäîðîâ'ÿ Àâòîíîìíî¿ Ðåñïóáë³êè Êðèì, íà÷àëüíèêàì óïðàâë³íü îõîðîíè çäîðîâ'ÿ îáëàñíèõ, Ñåâàñòîïîëüñüêî¿ ì³ñüêî¿ äåðæàâíèõ àäì³í³ñòðàö³é, Ãîëîâíîãî óïðàâë³ííÿ îõîðîíè çäîðîâ'ÿ òà ìåäè÷íîãî çàáåçïå÷åííÿ Êè¿âñüêî¿ ì³ñüêî¿ äåðæàâíî¿ àäì³í³ñòðàö³¿ çàáåçïå÷èòè âïðîâàäæåííÿ îáë³êîâèõ ñòàòèñòè÷íèõ ôîðì, ùî âèêîðèñòîâóþòüñÿ â îðãàíàõ ìåäèêî-ñîö³àëüíî¿ åêñïåðòèçè.
4. Íà÷àëüíèêó öåíòðó ìåäè÷íî¿ ñòàòèñòèêè /Ãîëóá÷èêîâó Ì. Â./ çàáåçïå÷èòè ïðàö³âíèê³â ñòàòèñòè÷íî¿ ñëóæáè îáëàñíîãî ð³âíÿ çðàçêàìè îáë³êîâèõ ôîðì, ùî âèêîðèñòîâóþòüñÿ â îðãàíàõ ÌÑÅÊ òà íàäàòè íåîáõ³äíó ³íñòðóêòèâíî-ìåòîäè÷íó äîïîìîãó.
5. Êîíòðîëü çà âèêîíàííÿì öüîãî íàêàçó ïîêëàñòè íà Çàñòóïíèêà Äåðæàâíîãî ñåêðåòàðÿ ̳í³ñòåðñòâà Î. Ì. Îðäó.
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̳í³ñòð |
À. Â. ϳäàºâ |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ | ||
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Íàéìåíóâàííÿ çàêëàäó | ||||
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1. _________________________________________________________ 2. _________________________________________________________ 3. _________________________________________________________ 4. ÀÊÒ N ______ ÎÃËßÄÓ ÌÑÅÊ
ïî âèçíà÷åííþ ìåäè÷íèõ ïîêàçàíü
6. _________________________________________________________ 7. Äàòà íàðîäæåííÿ 8. Àäðåñà ___________________________________________________ 9. Ãðóïà ³íâàë³äíîñò³ __________________________________________ 10. Ïðè÷èíà ³íâàë³äíîñò³ ______________________________________ | ||||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 156/î
12. Ðåçóëüòàòè åêñïåðòíîãî îáñë³äóâàííÿ
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Õ³ðóðã |
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ñòîð. 3 ô. N 156/î
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Îêóë³ñò |
Îòîëàðèíãîëîã |
Ïñèõ³àòð |
Íåâðîïàòîëîã |
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* Äîäàòè äîâ³äêó ïðî ñòàí çäîðîâ'ÿ ³ç ïñèõîíåâðîëîã³÷íîãî äèñïàíñåðó.
ñòîð. 4 ô. N 156/î
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13. Ðåçóëüòàòè äîäàòêîâèõ äîñë³äæåíü ____________________________ 14. Ïðèì³òêà __________________________________________________ 15. Îñíîâíèé ä³àãíîç __________________________________________ 16. Åêñïåðòíå ð³øåííÿ 16.1 ª ìåäè÷í³ ïîêàçàííÿ íà çàáåçïå÷åííÿ ________________________ ïåðåäáà÷åí³ ïóíêòîì ________ Ïåðåë³êó ìåäè÷íèõ ïîêàçàíü 16.2 Ïðèäàòíèé äî êåðóâàííÿ ___________________________________ 16.3 ª ìåäè÷í³ ïðîòèïîêàçàííÿ äî êåðóâàííÿ ______________________ çã³äíî ç ïóíêòîì ________ Ïåðåë³êó çàõâîðþâàíü ³ âàä, ïðè ÿêèõ 17. Ïåðåîãëÿä ________________________________________________ Ì. Ï.
Ãîëîâà ÌÑÅÊ ______________________ ×ëåíè _____________________________ ( ) |
Àêò îãëÿäó ÌÑÅÊ ïî âèçíà÷åííþ ìåäè÷íèõ ïîêàçàíü äëÿ çàáåçïå÷åííÿ ³íâàë³ä³â àâòîìîá³ëÿìè ñêëàäàºòüñÿ íà êîæíîãî ³íâàë³äà, ÿêèé ïðîõîäèòü îãëÿä ÌÑÅÊ.
Íà áëàíêó ïîâèííà áóòè ïðèêëåºíà ôîòîãðàô³ÿ îãëÿíóòîãî (3 õ 4).
Ïóíêò 4 "Íîìåð àêòà" â³äïîâ³äຠðåºñòðàö³éíîìó íîìåðó â æóðíàë³ ïðîòîêîë³â çàñ³äàíü ÌÑÅÊ çà ïîòî÷íèé ð³ê.
 ïóíêò³ 9 "Ãðóïà ³íâàë³äíîñò³" çàçíà÷àºòüñÿ ñåð³ÿ ³ íîìåð ñïðàâêè ÌÑÅÊ, äàòà ¿¿ âèäà÷³.
 ïóíêò³ 10 "Îãëÿä" âêàçàòè ïåðâèííèé ÷è ïîâòîðíèé îãëÿä.
 ïóíêò³ 14 "Ïðèì³òêà" âêàçóþòüñÿ äàí³ ïðî íàïðàâëåííÿ íà äîäàòêîâå îáñòåæåííÿ, êîíñóëüòàö³þ òà ³í.
 ïóíêò³ 16.1, ó âèïàäêó â³äñóòíîñò³ ìåäè÷íèõ ïîêàçàíü íà çàáåçïå÷åííÿ àâòîìîá³ëÿìè, ñòàâèòüñÿ çàïèñ "íåìàº".
 ïóíêò³ 17 "Ïåðåîãëÿä" çàçíà÷àºòüñÿ ñòðîê ïåðåîãëÿäó ó âèïàäêó íåîáõ³äíîñò³ äèíàì³÷íîãî ñïîñòåðåæåííÿ.
³äïîâ³äàëüí³ñòü çà ïðàâèëüí³ñòü çàïîâíåííÿ àêòà íåñå ãîëîâà ÌÑÅÊ.
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ | ||
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Íàéìåíóâàííÿ çàêëàäó | ||||
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____________________________________________________________ ____________________________________________________________ ÂÈÏÈÑÊÀ
³ç àêòà îãëÿäó ÌÑÅÊ ïî âèçíà÷åííþ ìåäè÷íèõ ïîêàçàíü äëÿ (íàäñèëàºòüñÿ â óïðàâë³ííÿ ïðàö³ ³ ñîö³àëüíîãî çàõèñòó íàñåëåííÿ) ____________________________________________________________ ____________________________________________________________ Äàòà íàðîäæåííÿ Äàòà îãëÿäó Ãðóïà ³íâàë³äíîñò³ ____________________________________________ ̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè
________________________________________ ____________________________________________________________ ÄβÄÊÀ N (äëÿ ïîäàííÿ äî äåðæàäì³í³ñòðàö³¿)
Äàòà îãëÿäó | ||||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
Ñòîð. 2 ô. N 156-1/î
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ÂÈÑÍÎÂÎÊ ª ìåäè÷í³ ïîêàçàííÿ äëÿ çàáåçïå÷åííÿ __________________________ ïåðåäáà÷åí³ ïóíêòîì ______________ Ïåðåë³êó ìåäè÷íèõ ïîêàçàíü íà îäåðæàííÿ ³íâàë³äàìè àâòîìîá³ëÿ, çàòâåðäæåíîãî ̳í³ñòåðñòâîì îõîðîíè çäîðîâ'ÿ Óêðà¿íè Ïðèäàòíèé äî êåðóâàííÿ ______________________________________ ª ìåäè÷í³ ïðîòèïîêàçàííÿ äî êåðóâàííÿ _________________________ çã³äíî ³ç ñò. _______ ðîçä³ëó ________ Ïåðåë³êó ìåäè÷íèõ ïðîòèïîêàçàíü, ùî ïåðåøêîäæàþòü äîïóñêó äî óïðàâë³ííÿ àâòîìîá³ëåì, çàòâåðäæåíîãî ̳í³ñòåðñòâîì îõîðîíè çäîðîâ'ÿ Óêðà¿íè Ïåðåîãëÿä ___________________________________________________ ϲÄÑÒÀÂÀ: àêò N ________ îãëÿäó ÌÑÅÊ ïî âèçíà÷åííþ ìåäè÷íèõ ïîêàçàíü äëÿ çàáåçïå÷åííÿ àâòîìîá³ëåì Äàòà Ì. Ï. Ãîëîâà ÌÑÅÊ _________________________________ ____________________________________________________________ ÂÈÑÍÎÂÎÊ Ïðèäàòíèé äî êåðóâàííÿ ______________________________________ Ïåðåîãëÿä ___________________________________________________ ϳäñòàâà: àêò N ____________ îãëÿäó ó ÌÑÅÊ ïî âèçíà÷åííþ ìåäè÷íèõ Äàòà Ì. Ï. Ãîëîâà ÌÑÅÊ ______________________________ |
Äàíèé äîêóìåíò º áëàíêîì ñóâîðîãî îáë³êó. Ïðè îäåðæàíí³, çáåð³ãàíí³ òà âèêîðèñòàíí³ áëàíê³â Âèïèñêè ³ç àêòà îãëÿäó ÌÑÅÊ ïî âèçíà÷åííþ ìåäè÷íèõ ïîêàçàíü äëÿ çàáåçïå÷åííÿ ³íâàë³ä³â àâòîìîá³ëÿìè òà Äîâ³äêè äî àêòà îãëÿäó ÌÑÅÊ ïî âèçíà÷åííþ ìåäè÷íèõ ïîêàçàíü äëÿ çàáåçïå÷åííÿ ³íâàë³ä³â àâòîìîá³ëÿìè ïîòð³áíî äîòðèìóâàòèñü âèìîã, ùî âñòàíîâëåí³ äëÿ áëàíê³â ñóâîðîãî îáë³êó.
Öåé áëàíê ïðèçíà÷åíèé äëÿ âíåñåííÿ ð³øåííÿ ÌÑÅÊ ïðî ïîòðåáó çàáåçïå÷åííÿ àâòîìîá³ëÿìè ³ ìîæëèâîñò³ äîïóùåííÿ ³íâàë³ä³â äî óïðàâë³ííÿ íèìè.
Âñ³ ðåêâ³çèòè çàïîâíþþòüñÿ â³äïîâ³äíî äî çàïèñ³â àíàëîã³÷íèõ ðåêâ³çèò³â â Àêò³ îãëÿäó ÌÑÅÊ ïî âèçíà÷åííþ ìåäè÷íèõ ïîêàçàíü äëÿ çàáåçïå÷åííÿ ³íâàë³ä³â àâòîìîá³ëÿìè.
Áëàíê çàïîâíþºòüñÿ ãîëîâîþ ìåäèêî-ñîö³àëüíî¿ åêñïåðòíî¿ êîì³ñ³¿, ùî ïðîâîäèòü ïîïåðåäí³é, ïåð³îäè÷íèé àáî ïîçà÷åðãîâèé îãëÿä âîä³ÿ (êàíäèäàòà ó âî䳿) òðàíñïîðòíîãî çàñîáó.
Öåé äîêóìåíò ï³äïèñóº ãîëîâà ÌÑÅÊ.
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ |
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Íàéìåíóâàííÿ çàêëàäó | ||
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ÄβÄÊÀ Âèäàíà ãð. ___________________________________________________________________________ Äàòà íàðîäæåííÿ ³íâàë³ä _________ ãðóïè _____________________________________________________________________________________ Äîìàøíÿ àäðåñà ______________________________________________________________________ â òîìó, ùî â³í (âîíà) îãëÿäàâñÿ(ëàñü) _____________________________________________________________________________________ Çà ðåçóëüòàòàìè îãëÿäó íå âñòàíîâëåí³ ìåäè÷í³ ïîêàçàííÿ äëÿ Ì. Ï. Ãîëîâà ÌÑÅÊ ______________________ | ||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
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Ïðèì³òêà. |
Äîâ³äêà âèäàºòüñÿ ãðîìàäÿíàì, äëÿ ÿêèõ, çà ðåçóëüòàòàìè îãëÿäó ÌÑÅÊ, íå âñòàíîâëåí³ ìåäè÷í³ ïîêàçàííÿ äëÿ çàáåçïå÷åííÿ àâòîìîá³ëåì. |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ | |
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Íàéìåíóâàííÿ çàêëàäó | |||
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ÆÓÐÍÀË
îáë³êó ïðîòîêîë³â çàñ³äàíü ÌÑÅÊ Ïî÷àòî "____" ___________ 20___ ð. Çàê³í÷åíî "____" _________ 20___ ð. | |||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 156-3/î
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Ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ |
гê íàðîä- |
Äîìàøíÿ àäðåñà |
Ãðóïà ³íâàë³ä- |
Êàòåãîð³ÿ ³íâàë³ä- |
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ñòîð. 3 ô. N 156-3/î
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ÊÎË N ____________ | |||
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Çàñ³äàííÿ ðîçïî÷àòî _____ ãîä. ____ õâ. Çàê³í÷åíî â ____ ãîä. ____ õâ. | |||
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Ìåäè÷í³ |
Âèñíîâêè êîì³ñ³¿ ç |
Ïðèì³òêà |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ |
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Íàéìåíóâàííÿ çàêëàäó | ||
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1. __________________________________________________________ 2. __________________________________________________________ 3. __________________________________________________________ 4. ÀÊÒ N __________ ÎÃËßÄÓ ÌÑÅÊ 5. _________________ 6. ___________________ 7. _________________ 8. __________________________________________________________ 9. _____________________________ 10. _________________________ 11. _________________________________________________________ 12. _________________________________________________________ 13. _________________________________________________________ 14. _________________________________________________________ 15. _________________________________________________________ 16. __________________________ 17. ____________________________ 18. __________________________19. ____________________________ 20. __________________________ 21. ____________________________ 22. _________________________________________________________ 23. _________________________________________________________ 24. _________________________________________________________ 25. _________________________________________________________ 26. _________________________________________________________ 27. _________________________________________________________ | ||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 157/î
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28. Ðåçóëüòàòè åêñïåðòíîãî îáñë³äóâàííÿ 28.1. Ñêàðãè 28.2. Ìåäèêî-ñîö³àëüíèé àíàìíåç 28.3. Òðèâàë³ñòü òèì÷àñîâî¿ íåïðàöåçäàòíîñò³ ______________________ 28.4. Îö³íêà ïðàöåâëàøòóâàííÿ _________________________________ 28.5. Âèêîíàííÿ ðåêîìåíäàö³é ïî â³äíîâëåííþ çäîðîâ'ÿ òà |
ñòîð. 3 ô. N 157/î
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28.6. Äàí³ îá'ºêòèâíîãî îáñë³äóâàííÿ ó ÌÑÅÊ 28.6.1. Äàí³ 28.6.2. Äàí³ |
ñòîð. 4 ô. N 157/î
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28.6.3. Äàí³ ___________________________________________________ 28.6.4. Äàí³ ë³êàð³â ³íøèõ ñïåö³àëüíîñòåé __________________________ |
ñòîð. 5 ô. N 157/î
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28.6.5. Ðåçóëüòàòè äîäàòêîâèõ îáñë³äóâàíü 28.6.5. Äîäàòêîâ³ äàí³ 29. ijàãíîç ___________________________________________________ 29.1. Îñíîâíèé ä³àãíîç 29.2. Ñóïóòí³é ä³àãíîç |
ñòîð. 6 ô. N 157/î
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30. Åêñïåðòíå ð³øåííÿ: 30.1. Âèñíîâîê ïðî óìîâè ³ õàðàêòåð ïðàö³ ________________________ 30.2. Ðåêîìåíäàö³¿ ïî ñîö³àëüíî-òðóäîâ³é ðåàá³ë³òàö³¿ 30.3. Ðåêîìåíäàö³¿ ïî ìåäè÷í³é ðåàá³ë³òàö³¿ ________________________ 30.4. Ãðóïà ³íâàë³äíîñò³ ________________________________________ 30.5. Ïðè÷èíà ³íâàë³äíîñò³ ______________________________________ 30.6. ²íâàë³äí³ñòü âñòàíîâëåíà íà ñòðîê 30.7. Äàòà ÷åðãîâîãî ïåðåîãëÿäó _________________________________ 30.8. ×àñ íàñòàííÿ ³íâàë³äíîñò³ __________________________________ 31. Ñòóï³íü âòðàòè ïðîôåñ³éíî¿ ïðàöåçäàòíîñò³ ó â³äñîòêàõ 31.1. ________________________________________________________ 31.2. Çà ìèíóëèé ÷àñ __________________________________________ |
ñòîð. 7 ô. N 157/î
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32. Ïîòðåáà ó äîäàòêîâèõ âèäàõ äîïîìîãè _________________________ 33. Äîêóìåíòè, ùî º ï³äñòàâîþ äëÿ âèíåñåííÿ åêñïåðòíîãî 34. Îá´ðóíòóâàííÿ åêñïåðòíîãî ä³àãíîçó 35. Îá´ðóíòîâàí³ñòü íàïðàâëåííÿ íà ÌÑÅÊ 36. Äîâ³äêà ñåð. _________ N __________ Ãîëîâà ÌÑÅÊ ____________________ ( ) ×ëåíè ___________________________ ( ) Ì. Ï. |
ñòîð. 8 ô. N 157/î
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37. Çàóâàæåííÿ òà ïðîïîçèö³¿ îáëàñíî¿ (öåíòðàëüíî¿ ì³ñüêî¿) ÌÑÅÊ ïî ðåçóëüòàòàõ ïåðåâ³ðêè ïðàâèëüíîñò³ âèð³øåííÿ ³ îôîðìëåííÿ àêòà îãëÿäó ðàéîííî¿, ì³æðàéîííî¿, ì³ñüêî¿ ìåäèêî-ñîö³àëüíî¿ åêñïåðòíî¿ êîì³ñ³¿ | ||
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Äàòà |
Çàóâàæåííÿ, ïðîïîçèö³¿ |
ϳäïèñ |
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Àêò îãëÿäó ÌÑÅÊ (äàë³ - Àêò) ïðèçíà÷åíèé äëÿ çàïèñó îñíîâíèõ ìåäè÷íèõ äàíèõ ³ ñîö³àëüíèõ ôàêòîð³â, íåîáõ³äíèõ äëÿ âèíåñåííÿ åêñïåðòíîãî ð³øåííÿ òà éîãî îá´ðóíòóâàííÿ.  Àêò³ âêàçóþòüñÿ óìîâè ³ õàðàêòåð ïðàö³, ÿê³ ðåêîìåíäóþòüñÿ ³íâàë³äàì, òà ³íø³ çàõîäè, ÿê³ ñïðèÿþòü â³äíîâëåííþ ¿õ ïðàöåçäàòíîñò³.
Àêò ñêëàäàºòüñÿ íà êîæíîãî õâîðîãî, ÿêèé îãëÿäàºòüñÿ ó ÌÑÅÊ.
Óñ³ ïóíêòè àêòà çàïîâíþþòüñÿ ðîçá³ðëèâî.
Ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ çàïèñóþòüñÿ ïîâí³ñòþ çã³äíî ç ïàñïîðòíèìè äàíèìè.
Ïóíêò 3 "Âèä, ïðîô³ëü ÌÑÅÊ". Âèä ÌÑÅÊ: Êðèìñüêà ðåñïóáë³êàíñüêà, îáëàñíà, öåíòðàëüíà ì³ñüêà, ì³ñüêà, ì³æðàéîííà, ðàéîííà; ïðîô³ëü ÌÑÅÊ: çàãàëüíèé, ñïåö³àë³çîâàíèé: äëÿ îãëÿäó õâîðèõ íà òóáåðêóëüîç, ïñèõ³÷í³ ðîçëàäè, çàõâîðþâàííÿ ³ äåôåêòè îðãàíó çîðó, ñåðöåâî-ñóäèíí³ çàõâîðþâàííÿ òà ³íø³.
Ïóíêò 4 "Íîìåð äîêóìåíòà" (ïðîñòàâëÿºòüñÿ àðàáñüêèìè öèôðàìè) â³äïîâ³äຠðåºñòðàö³éíîìó íîìåðó â æóðíàë³ ïðîòîêîë³â çàñ³äàíü ÌÑÅÊ çà ïîòî÷íèé ð³ê.
 ïóíêò³ 5 "Äàòà ïî÷àòêó åêñïåðòèçè" âêàçóºòüñÿ äàòà íàäõîäæåííÿ ó ÌÑÅÊ "Íàïðàâëåííÿ íà ÌÑÅÊ" (ôîðìà N 088/î) ç ë³êóâàëüíî-ïðîô³ëàêòè÷íèõ çàêëàä³â.
 ïóíêò³ 7 "Äàòà çàê³í÷åííÿ åêñïåðòèçè" çàçíà÷àºòüñÿ äàòà ïðèéíÿòòÿ ð³øåííÿ ÌÑÅÊ.
 ïóíêò³ 25 "Õàðàêòåð òà óìîâè ïðàö³" âêàçóºòüñÿ íàéá³ëüø ïåðåâàæàþ÷èé âèðîáíè÷èé ôàêòîð, ñòóï³íü âèðàæåíîñò³ ô³çè÷íî¿ àáî íåðâîâî-ïñèõîëîã³÷íî¿ íàïðóãè, ðîáî÷à ïîçà, òåìï ðîáîòè, êîíòàêòè ç òîêñè÷íèìè ðå÷îâèíàìè, òåìïåðàòóðà, âîëîã³ñòü, ïåðåáóâàííÿ â ãó÷íîìó, ïèëüíîìó, æàðêîìó ïðèì³ùåíí³, í³÷í³ çì³íè, êîìàíäèðîâêè, ðîç'¿çäè òà ³íø³.
 ïóíêò³ 30.1 "Âèñíîâîê ïðî óìîâè òà õàðàêòåð ïðàö³" çàçíà÷àþòüñÿ ïîêàçàí³ òà ïðîòèïîêàçàí³ óìîâè ïðàö³, à òàêîæ îð³ºíòîâí³ âèäè ïðàö³, ðîá³ò ÷è ïðîôåñ³¿, ÿê³ äîñòóïí³ ³íâàë³äó çà ñòàíîì çäîðîâ'ÿ.
 ïóíêò³ 30.2 "Ðåêîìåíäàö³¿ ç ñîö³àëüíî-òðóäîâî¿ ðåàá³ë³òàö³¿" çàçíà÷àºòüñÿ ïîòðåáà ³íâàë³äà â íàâ÷àíí³, ïåðåêâàë³ô³êàö³¿, ïåðåíàâ÷àíí³, çàáåçïå÷åíí³ çàñîáàìè ïåðåñóâàííÿ, ³íøèõ âèäàõ, íàïðàâëåíèõ íà â³äíîâëåííÿ ïðàöåçäàòíîñò³ ³íâàë³äà.
 ïóíêò³ 30.3 "Ðåêîìåíäàö³¿ ç ìåäè÷íî¿ ðåàá³ë³òàö³¿" çàçíà÷àºòüñÿ ïîòðåáà ³íâàë³äà â íàïðàâëåíí³ íà â³äíîâíå ñàíàòîðíî-êóðîðòíå ë³êóâàííÿ òà ³í. Ö³ çàõîäè ïîâèíí³ áóòè çàíåñåí³ ó â³äðèâíèé òàëîí "Íàïðàâëåííÿ íà ÌÑÅÊ" (ôîðìà N 088/î).
 ïóíêò³ 30.4 "Ãðóïà ³íâàë³äíîñò³" ïðèçíà÷åíà ãðóïà âêàçóºòüñÿ ïðîïèñîì, à äëÿ îñ³á, íå âèçíàíèõ ³íâàë³äàìè, ñòàâèòüñÿ çàïèñ "íå âñòàíîâëåíî".
 ïóíêò³ 33 "Äîêóìåíòè, ÿê³ áóëè ï³äñòàâîþ äëÿ âèíåñåííÿ åêñïåðòíîãî ð³øåííÿ" ïåðåðàõîâóþòüñÿ âñ³ äîêóìåíòè, ÿê³ ñòàëè îñíîâîþ äëÿ ïðèéíÿòòÿ ð³øåííÿ ÌÑÅÊ, âêàçóºòüñÿ íàçâà óñòàíîâè, ÿêà âèäàëà äîêóìåíò, äàòà ³ íîìåð êîæíîãî äîêóìåíòà, êîðîòêî âèêëàäàºòüñÿ çì³ñò ò³º¿ ÷àñòèíè äîêóìåíòà, ÿêà ñòàëà îñíîâîþ äëÿ ïðèéíÿòòÿ ð³øåííÿ ïðî ïðè÷èíó, ÷àñ íàñòàííÿ ³íâàë³äíîñò³, ñòóï³íü âòðàòè ïðàöåçäàòíîñò³ ³ ò. ³í.
 ïóíêò³ 34 "Ñòèñëå îá´ðóíòóâàííÿ åêñïåðòíîãî ð³øåííÿ" çàçíà÷àºòüñÿ îá´ðóíòóâàííÿ ïðèéíÿòîãî ð³øåííÿ ïðî ãðóïó, ïðè÷èíó, ÷àñ íàñòàííÿ ³íâàë³äíîñò³, ñòóï³íü âòðàòè ïðîôåñ³éíî¿ ïðàöåçäàòíîñò³, ïîòðåáà â äîäàòêîâèõ âèäàõ äîïîìîãè, â íåîáõ³äíèõ âèïàäêàõ, ïîñèëàþ÷èñü íà â³äïîâ³äíèé ïóíêò íîðìàòèâíîãî äîêóìåíòà.
 ïóíêò³ 35 "Îá´ðóíòîâàí³ñòü íàïðàâëåííÿ íà ÌÑÅÊ" âêàçóºòüñÿ: îá´ðóíòîâàíî ÷è íåîá´ðóíòîâàíî íàïðàâëåíî ãðîìàäÿíèíà íà ÌÑÅÊ.
Ïóíêò 37 çàïîâíþºòüñÿ îáëàñíîþ (öåíòðàëüíîþ ì³ñüêîþ) ÌÑÅÊ çà ðåçóëüòàòàìè ïåðåâ³ðîê.
Âñ³ âèïðàâëåííÿ, äîïîâíåííÿ, çì³íè, âíåñåí³ â Àêò ïîâèíí³ áóòè îáóìîâëåí³, ï³äïèñàí³ ãîëîâîþ, ÷ëåíàìè êîì³ñ³¿ ³ çàâ³ðåí³ ïå÷àòêîþ ÌÑÅÊ.
Òåðì³í çáåð³ãàííÿ Àêòà - 50 ðîê³â.
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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ÁËÀÍÊ ÑÓÂÎÐÎÃÎ ÎÁ˲ÊÓ |
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Íàéìåíóâàííÿ çàêëàäó | ||
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_____________________________________________________________ ÂÈÏÈÑÊÀ ²Ç ÀÊÒÀ ÎÃËßÄÓ ÌÑÅÊ
Äî äîâ³äêè Ñåð. N __________________ ___________________________________ Äàòà íàðîäæåííÿ Àäðåñà _______________________ _____________________________________________________________ Ãðóïà ³íâàë³äíîñò³ _____________________________ Ïðè÷èíà ³íâàë³äíîñò³ __________________________________________ Äàòà ÷åðãîâîãî ïåðåîãëÿäó Âèñíîâêè ìåäèêî-ñîö³àëüíèõ (åêñïåðòíèõ) êîì³ñ³é ïðî óìîâè ³ õàðàêòåð ïðàö³ ³íâàë³ä³â º îáîâ'ÿçêîâèìè äëÿ àäì³í³ñòðàö³¿ ï³äïðèºìñòâ, óñòàíîâ ³ îðãàí³çàö³é. ̲ͲÑÒÅÐÑÒÂÎ ÎÕÎÐÎÍÈ ÇÄÎÐÎÂ'ß ÓÊÐÀ¯ÍÈ
___________________________________ ÄβÄÊÀ Ñåð³ÿ N ____________________ _____________________________________________________________ Äàòà íàðîäæåííÿ Äàòà îãëÿäó Îãëÿä _______________________________________________________ Ãðóïà ³íâàë³äíîñò³ ____________________________________________ Ïðè÷èíà ³íâàë³äíîñò³ _________________________________________ ²íâàë³äí³ñòü âñòàíîâëåíà íà ñòðîê äî 1 ______________ 20__ ð. Äàòà ÷åðãîâîãî ïåðåîãëÿäó | ||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 157-1/î
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ijàãíîç ÌÑÅÊ ________________________________________________ Âèñíîâîê ïðî óìîâè òà õàðàêòåð ïðàö³ _____________________________________________________________ Ðåêîìåíäîâàí³ çàõîäè ïî â³äíîâëåííþ ïðàöåçäàòíîñò³ ϳäñòàâà: àêò N __________________ îãëÿä ÌÑÅÊ __________________ Äàòà Ãîëîâà ÌÑÅÊ _________________ (________________) __________________________________ Âèñíîâîê ïðî óìîâè òà õàðàêòåð ïðàö³
_____________________________________________________________ Ðåêîìåíäîâàí³ çàõîäè ïî â³äíîâëåííþ ïðàöåçäàòíîñò³ ϳäñòàâà: àêò N _________________ îãëÿä ÌÑÅÊ ___________________ Äàòà Ì. Ï. Ãîëîâà ÌÑÅÊ _____________ (_____________________) |
1. Öåé äîêóìåíò º áëàíêîì ñóâîðîãî îáë³êó. Ïðè îäåðæàíí³, çáåð³ãàíí³ òà âèêîðèñòàíí³ öèõ áëàíê³â ïîòð³áíî äîòðèìóâàòèñü âèìîã, ùî âñòàíîâëåí³ äëÿ áëàíê³â ñóâîðîãî îáë³êó.
2. Áëàíê ïðèçíà÷åíèé äëÿ âíåñåííÿ ð³øåííÿ ÌÑÅÊ ïðî âñòàíîâëåííÿ ãðóïè, ïðè÷èíè ³ ñòðîêó ³íâàë³äíîñò³.
3. Âñ³ ðåêâ³çèòè äàíîãî áëàíêà çàïîâíþþòüñÿ â³äïîâ³äíî äî çàïèñó àíàëîã³÷íèõ ðåêâ³çèò³â (àêòà îãëÿäó ÌÑÅÊ).
4. Áëàíê ï³äïèñóºòüñÿ ãîëîâîþ ÌÑÅÊ (ï³äïèñ ðîçøèôðîâóºòüñÿ) ³ çàñâ³ä÷óºòüñÿ ïå÷àòêîþ ÌÑÅÊ.
5. ³äïîâ³äàëüí³ñòü çà ïðàâèëüí³ñòü çàïîâíåííÿ íåñå ãîëîâà ÌÑÅÊ.
6. Òðèâàë³ñòü çáåð³ãàííÿ - 50 ðîê³â.
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ |
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Íàéìåíóâàííÿ çàêëàäó | ||
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ÂÈÑÍÎÂÎÊ â³ä "____" ____________ 20__ ðîêó _____________________________________________________________ ðîçãëÿíóëà ìåäè÷íó äîêóìåíòàö³þ ãð. __________________________________________________________ ç ìåòîþ âèçíà÷åííÿ ó íüîãî ÷àñó íàñòàííÿ ³íâàë³äíîñò³. ϳä ÷àñ ðîçãëÿäó âñòàíîâëåíî ñë³äóþ÷å: ________________________ Âðàõîâóþ÷è âèêëàäåíå âèùå, ÌÑÅÊ ââàæàº, ùî ãð. __________________________________________________________ çà ä³àãíîçîì: __________________________________________________ ç "____"____________ 20__ ð. âèçíàºòüñÿ ³íâàë³äîì _______________ ãðóïè ϳäòâåðäæóþ÷³ äîêóìåíòè: _____________________________________________________________ Ì. Ï. Ãîëîâà ÌÑÅÊ __________________________ | ||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
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Ïðèì³òêà. |
Âèñíîâîê âèäàºòüñÿ ³íâàë³äó ó ðàç³, ÿêùî ÷àñ íàñòàííÿ ³íâàë³äíîñò³ íå ñï³âïàäຠç äàòîþ, ÿêà çàçíà÷åíà ó Äîâ³äö³ àêòà îãëÿäó ÌÑÅÊ, ÷è â ³íøèõ âèïàäêàõ. ×àñ íàñòàííÿ ³íâàë³äíîñò³ ìຠáóòè ï³äòâåðäæåíèé äîâ³äêàìè, ïðî ùî ³ çàçíà÷àºòüñÿ ó âèñíîâêó. |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ |
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Íàéìåíóâàííÿ çàêëàäó | ||
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Äîâ³äêà Âèäàíà ãð. ___________________________________________________________________________ Äàòà íàðîäæåííÿ ³íâàë³ä __________________________ ãðóïè _____________________________________________________________________________________ Äîìàøíÿ àäðåñà ______________________________________________________________________ â òîìó, ùî â³í (âîíà) ___________________ îãëÿäàâñÿ(ëàñü) _____________________________________________________________________________________ Çà ñòàíîì çäîðîâ'ÿ ìîæå çíàõîäèòèñü â áóäèíêó-³íòåðíàò³ äëÿ ïñèõîõðîí³ê³â Ì. Ï. Ãîëîâà ÌÑÅÊ ______________________________ | ||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ | |
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Íàéìåíóâàííÿ çàêëàäó | |||
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ÆÓÐÍÀË Ïî÷àòî "____" ___________ 20__ ð. Çàê³í÷åíî "____" ___________ 20__ ð. | |||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 157-4/î
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Äàòà âèäà÷³ äîâ³äêè |
Ïð³çâèùå, ³ì'ÿ ³íâàë³äà, ÿêèé îòðèìàâ äîâ³äêó |
Ñåð³ÿ ³ íîìåð äîâ³äêè |
Íîìåð àêòà îãëÿäó |
ϳäïèñ â îòðèìàíí³ äîâ³äêè |
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Òåðì³í çáåð³ãàííÿ Æóðíàëó îáë³êó äîâ³äîê ÌÑÅÊ, âèäàíèõ ³íâàë³äàì, - 50 ðîê³â.
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ | ||
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Íàéìåíóâàííÿ çàêëàäó | ||||
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ÆÓÐÍÀË Ïî÷àòî "____" ___________ 20__ ð. Çàê³í÷åíî "____" ___________ 20__ ð. | ||||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 157-5/î
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ÏÐÎÒÎ
çàñ³äàííÿ ÌÑÅÊ â³ä "___" ___________ 20__ ðîêó | ||||||
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Ïð³çâèùå, ³ì'ÿ, |
гê |
Äîìàøíÿ |
Ïðîôåñ³ÿ |
Êèì |
Ãðóïà ³ ïðè÷èíà |
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ñòîð. 3 ô. N 157-5/î
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ÊÎË N ____________ | ||||||
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Çàñ³äàííÿ ðîçïî÷àòî _____ ãîä. ____ õâ. Çàê³í÷åíî ____ ãîä. ____ õâ. | ||||||
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вØÅÍÍß ÌÑÅÊ |
IJÀÃÍÎÇ |
Øèôð |
Ïðèì³ò- | |||
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ãðóïà |
ïðè÷èíà |
ñòðîê |
òðóäîâà | |||
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Òåðì³í çáåð³ãàííÿ Æóðíàëó ïðîòîêîë³â çàñ³äàíü ÌÑÅÊ - 50 ðîê³â.
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Áëàíê ñóâîðîãî îáë³êó |
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Íàéìåíóâàííÿ çàêëàäó | ||
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Ñåð³ÿ_________________ N ________________ __________________________________________________________ ÄβÄÊÀ _____________________________________________________________ _____________________________________________________________ ̲ͲÑÒÅÐÑÒÂÎ ÎÕÎÐÎÍÈ ÇÄÎÐÎÂ'ß ÓÊÐÀ¯ÍÈ Ñåð³ÿ_________________ N _________________ _____________________________________________________________ ÄβÄÊÀ _____________________________________________________________ Äàòà îãëÿäó | ||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 158/î
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Ñòóï³íü âòðàòè ïðîôåñ³éíî¿ ïðàöåçäàòíîñò³ ó â³äñîòêàõ: _____________________________________________________________ ó çâ'ÿçêó ç ____________________________________________________ â³ä __________________________________________________________ ϳäñòàâà: àêò N _____________ îãëÿäó ÌÑÅÊ Äàòà îãëÿäó Ì. Ï. Ãîëîâà ÌÑÅÊ _________________________ __________________________________ Ñòóï³íü âòðàòè ïðîôåñ³éíî¿ ïðàöåçäàòíîñò³ ó â³äñîòêàõ: _____________________________________________________________ ϳäñòàâà: àêò N _____________ îãëÿäó ÌÑÅÊ Äàòà Ì. Ï. Ãîëîâà ÌÑÅÊ _________________________ |
1. Áëàíê Äîâ³äêè ïðî ðåçóëüòàòè âèçíà÷åííÿ ñòóïåíÿ âòðàòè ïðîôåñ³éíî¿ ïðàöåçäàòíîñò³ ó â³äñîòêàõ çàñòðàõîâàíîãî º áëàíêîì ñóâîðîãî îáë³êó; ïðè îäåðæàíí³, çáåð³ãàíí³ òà âèêîðèñòàíí³ áëàíê³â Äîâ³äêè ïîòð³áíî äîòðèìóâàòèñü âèìîã, ùî âñòàíîâëåí³ äëÿ áëàíê³â ñóâîðîãî îáë³êó.
2. Öåé áëàíê ïðèçíà÷åíèé äëÿ çàíåñåííÿ â³äïîâ³äíîãî ð³øåííÿ ìåäèêî-ñîö³àëüíî¿ åêñïåðòíî¿ êîì³ñ³¿ ïðè îãëÿä³ ïðàö³âíèê³â, ùî ï³äëÿãàþòü äåðæàâíîìó îáîâ'ÿçêîâîìó îñîáèñòîìó ñòðàõóâàííþ, ó ðàç³ âòðàòè íèìè ïðàöåçäàòíîñò³ â ðåçóëüòàò³ ïîðàíåííÿ (êîíòó糿, òðàâìè àáî êàë³öòâà), çàõâîðþâàííÿ, ùî ñòàëèñÿ ïðè âèêîíàíí³ ñëóæáîâèõ îáîâ'ÿçê³â.
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Áëàíê ñóâîðîãî îáë³êó |
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Íàéìåíóâàííÿ çàêëàäó | ||
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_____________________________________________________________ _____________________________________________________________ ÂÈÏÈÑÊÀ Ç ÀÊÒÀ ÎÃËßÄÓ ÌÑÅÊ äî äîâ³äêè ñå𳿠_________ N __________________ _____________________________________________________________ Äàòà îãëÿäó Ãðóïà ³íâàë³äíîñò³ ____________ Îãëÿä :__________________________ (âêàçàòè: ïåðâèííèé, ïîâòîðíèé) __________________________________ ---------------------------------------------------Ë²Í²ß Â²ÄвÇÓ------------------------------------------------ _____________________________________________________________ _____________________________________________________________ ÄβÄÊÀ Ñåð³ÿ ______________ N ___________________ _____________________________________________________________ Äàòà îãëÿäó Ãðóïà ³íâàë³äíîñò³: _____________ Îãëÿä: __________________ (âêàçàòè ïðîïèñîì: ïåðâèííèé, ïîâòîðíèé) | ||
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*Ôîíä ñîö³àëüíîãî ñòðàõóâàííÿ â³ä íåùàñíèõ âèïàäê³â íà âèðîáíèöòâ³ òà ïðîôåñ³éíèõ çàõâîðþâàíü Óêðà¿íè.
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 158-1/î
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Ñòóï³íü âòðàòè ïðîôåñ³éíî¿ ïðàöåçäàòíîñò³ ó â³äñîòêàõ:
_____________________________________________________________ ó çâ'ÿçêó ç ____________________________________________________ â³ä __________________________________________________________ Äàòà ïåðåîãëÿäó Ïîòðåáà ó äîäàòêîâèõ âèäàõ äîïîìîãè: ___________________________ ϳäñòàâà: àêò N ____________ îãëÿäó ÌÑÅÊ Äàòà îãëÿäó Ì. Ï. Ãîëîâà ÌÑÅÊ ______________________ _____________________________________________________________ Ñòóï³íü âòðàòè ïðîôåñ³éíî¿ ïðàöåçäàòíîñò³ ó â³äñîòêàõ:
_____________________________________________________________ Äàòà ïåðåîãëÿäó Ïîòðåáà ó äîäàòêîâèõ âèäàõ äîïîìîãè :___________________________ ϳäñòàâà: àêò N ____________ îãëÿäó ÌÑÅÊ Äàòà Ì. Ï. Ãîëîâà ÌÑÅÊ ______________________ |
1. Áëàíê Âèïèñêè ç àêòà îãëÿäó ÌÑÅÊ ïðî ðåçóëüòàòè âèçíà÷åííÿ ñòóïåíÿ âòðàòè ïðîôåñ³éíî¿ ïðàöåçäàòíîñò³ ó â³äñîòêàõ, ïîòðåáè ó äîäàòêîâèõ âèäàõ äîïîìîãè òà Äîâ³äêè ïðî ðåçóëüòàòè âèçíà÷åííÿ ñòóïåíÿ âòðàòè ïðîôåñ³éíî¿ ïðàöåçäàòíîñò³ ó â³äñîòêàõ, ïîòðåáè ó äîäàòêîâèõ âèäàõ äîïîìîãè º áëàíêîì ñóâîðîãî îáë³êó; ïðè îäåðæàíí³, çáåð³ãàíí³ òà âèêîðèñòàíí³ áëàíê³â Äîâ³äêè ïîòð³áíî äîòðèìóâàòèñü âèìîã, ùî âñòàíîâëåí³ äëÿ áëàíê³â ñóâîðîãî îáë³êó.
2. Öåé áëàíê ïðèçíà÷åíèé äëÿ çàíåñåííÿ â³äïîâ³äíîãî ð³øåííÿ ìåäèêî-ñîö³àëüíî¿ åêñïåðòíî¿ êîì³ñ³¿ ïðè îãëÿä³ ïîòåðï³ëîãî âíàñë³äîê òðóäîâîãî êàë³öòâà ÷è ïðîôåñ³éíîãî çàõâîðþâàííÿ.
3. Òåðì³í çáåð³ãàííÿ - 50 ðîê³â.
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ |
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Íàéìåíóâàííÿ çàêëàäó | ||
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ÂÈÏÈÑÊÀ
ç àêòà îãëÿäó ÌÑÅÊ N _____ â³ä "____" ____________ 20__ ð. Çà íàïðàâëåííÿì ______________________________________________________________________ ³ä Ãð. _________________________________________________________________________________ Ïðîõîäèâ(ëà) îãëÿä â ___________________________________________________________ ÌÑÅÊ Àêò ïðî íåùàñíèé âèïàäîê íà âèðîáíèöòâ³ N _____ â³ä "____" _____________ 20__ ð. | ||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
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ijàãíîç ÌÑÅÊ: ________________________________________________________________________ ÌÑÅÊ âñòàíîâèëà, ùî ó ãð. _____________________________________________________________ âòðàòà ïðîôåñ³éíî¿ ïðàöåçäàòíîñò³ ñêëàäàº: ________________________________________________ íà ïåð³îä ç "____" ____________ äî "____" ____________ 20__ ð. Òåðì³í ïåðåîãëÿäó "____" ____________ 20__ ð. Ïîòðåáà ó äîäàòêîâèõ âèäàõ äîïîìîãè: ___________________________________________________ Âèñíîâîê ïðî óìîâè ³ õàðàêòåð ïðàö³ ______________________________________________________ Ãîëîâà ÌÑÅÊ: ×ëåíè êîì³ñ³¿: |
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Ïðèì³òêà. |
Âèïèñêà âèäàºòüñÿ çà çàïèòîì ï³äïðèºìñòâà, óñòàíîâè, îðãàí³çàö³¿, Ôîíäó ñîö³àëüíîãî ñòðàõóâàííÿ â³ä íåùàñíèõ âèïàäê³â íà âèðîáíèöòâ³ òà ïðîôåñ³éíèõ çàõâîðþâàíü. |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ |
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Íàéìåíóâàííÿ çàêëàäó | ||
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ÑÒÀÒÈÑÒÈ×ÍÈÉ ÒÀËÎÍ ÅÊÑÏÅÐÒÍÎÃÎ ÎÁÑÒÅÆÅÍÍß N ____________________________________________________________________ Êîä: Äàòà íàðîäæåííÿ Ñòàòü: ______________ Ìåäïðàö³âíèê: Àäðåñà ____________________________________ îáëàñòü __________________________________ ðàéîí ________________________ âóë. _______________________ áóä. N ________ êâ. N _______ îá'ºêòè óïðàâë³ííÿ îñâ³òà ____________________ ïðàöþº _____________________ îáë³ê Íàïðàâëåíèé (êèì): ___________________________________________________________________ ijàãíîç ïðè íàïðàâëåíí³ íà ÌÑÅÊ (øèôð ïî ÌÊÕ-10 ________________): îñíîâíèé: ____________________________________________________________________________ óñêëàäíåííÿ: _________________________________________________________________________ | ||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 159/î
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Êîä ÌÑÅÊ Êîì³ñ³ÿ _______________________________________________________ Äàòà îãëÿäó | |||||||
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Øèôð |
Ìåòà îãëÿäó |
Âèïàäîê |
Ïîïåðåäíÿ |
Âñòàíîâëåíà |
Ñòðîê | ||
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̳ñöå îãëÿäó:
Ãîëîâà ÌÑÅÊ ___________________________ | |||||||
Ñòàòèñòè÷íèé òàëîí ïðèçíà÷åíèé äëÿ êîìï'þòåðíî¿ îáðîáêè ñòàòèñòè÷íî¿ çâ³òíîñò³ ³ çàïîâíþºòüñÿ íà âñ³õ õâîðèõ, ÿê³ çâåðíóëèñü íà îãëÿä ÌÑÅÊ.
Çàïîâíåí³ ñòàòèñòè÷í³ òàëîíè ùîì³ñÿ÷íî ïåðåäàþòüñÿ äëÿ ïåðåâ³ðêè ë³êàðþ-ñòàòèñòèêó â ñë³äóþ÷³ ñòðîêè:
- ùîì³ñÿ÷íî äî 1-ãî ÷èñëà çà ìèíóëèé ì³ñÿöü;
- â îñòàíí³é ì³ñÿöü êâàðòàëó - â äâà åòàïè:
ïåðøà ïîëîâèíà äîêóìåíò³â - äî 20-ãî ÷èñëà;
äðóãà - äî 5-ãî ÷èñëà.
˳êàð-ñòàòèñòèê, ïåðåâ³ðèâøè çàïîâíåííÿ äîêóìåíò³â ó ïðèñóòíîñò³ îñîáè, ÿêà ¿õ çäàº, ïåðåäຠ¿õ îïåðàòîðó äëÿ ïîäàëüøîãî çàíåñåííÿ â ÅÎÌ.
Ç ìåòîþ ñòâîðåííÿ áàíêó äàíèõ ³íâàë³ä³â ó ÌÑÅÊ ñòàòèñòè÷í³ òàëîíè çàïîâíþþòüñÿ ÿê íà ïåðâèííèõ, òàê ³ íà ïîâòîðíî îãëÿíóòèõ ³íâàë³ä³â.
Êîæíîìó õâîðîìó íàäàºòüñÿ îñîáèñòèé êîä, ÿêèé ñêëàäàºòüñÿ ç êîäó ÌÑÅÊ, ïåðøî¿ ë³òåðè ïð³çâèùà òà íîìåðà çàïèñó â æóðíàë³ ïðîòîêîë³â.
Ñòàòèñòè÷íèé òàëîí âèêîðèñòîâóºòüñÿ áàãàòîðàçîâî. Íàäàë³ â íüîìó ³ç çàãàëüíèõ äàíèõ çàïîâíþþòüñÿ ò³ëüêè ò³, ùî çì³íèëèñÿ, òà ïîâí³ñòþ âèñíîâîê ÌÑÅÊ. Íà êîíñóëüòàòèâíèõ õâîðèõ êîä íå ïðîñòàâëÿºòüñÿ.
 ñòàòèñòè÷íîìó òàëîí³ ïðîñòàâëÿþòüñÿ êîäè, çã³äíî êëàñèô³êàòîð³â, ùî äîäàþòüñÿ. Öå äîçâîëÿº çàíîñèòè âñþ ³íôîðìàö³þ ³ç ñòàòèñòè÷íîãî òàëîíà â ïåðñîíàëüíó ÅÎÌ.
 êîæí³é îáëàñò³ â êëàñèô³êàòîð âíîñÿòüñÿ äàí³, ùî ñòîñóþòüñÿ íàçâè ÌÑÅÊ, à òàêîæ áóäü-ÿêà ³íøà ³íôîðìàö³ÿ çã³äíî ïîòðåá êîðèñòóâà÷à.
Íà ïåðø³é ñòîð³íö³ áëàíêà çàïîâíþþòüñÿ äàí³ ïðî ïàö³ºíòà çã³äíî ç ðåêâ³çèòàìè Àêòà îãëÿäó ÌÑÅÊ, à òàêîæ ïðîñòàâëÿºòüñÿ éîãî êîä.
"Ìåäïðàö³âíèê" - âêàçàòè êîä êëàñèô³êàòîðà çã³äíî äîäàòêà N 12.
"Ñîö³àëüíà êàòåãîð³ÿ" - êîä çã³äíî äîäàòêà N 2.
"Îá'ºêòè óïðàâë³ííÿ" - êîä çã³äíî äîäàòêà N 3.
"Ïðàöþº" - âêàçàòè ò³ëüêè äëÿ ïðàöþþ÷èõ ³íâàë³ä³â, â ³íøèõ âèïàäêàõ - ïðî÷åðê.
"Îáë³ê" - êîä çã³äíî äîäàòêà N 4.
"Íàïðàâëåíèé (êèì)" - âêàçàòè íàéìåíóâàííÿ ë³êóâàëüíîãî çàêëàäó, ÿêèé íàïðàâèâ õâîðîãî íà îãëÿä.
Íà çâîðîòí³é ñòîð³íö³ áëàíêà çàïîâíþºòüñÿ âèñíîâîê ÌÑÅÊ â ñë³äóþ÷îìó ïîðÿäêó:
"Êîä ÌÑÅÊ" - êîä çã³äíî äîäàòêà N 1.
"Êîì³ñ³ÿ" - âêàçàòè âèä, ïðîô³ëü ìåäèêî-ñîö³àëüíî¿ åêñïåðòíî¿ êîì³ñ³¿.
"Äàòà îãëÿäó" - âêàçàòè äàòó çàíåñåííÿ çàïèñó ïðî îãëÿä â ïðîòîêîë ÌÑÅÊ.
"Øèôð" - âêàçóºòüñÿ øèôð ïî ÌÊÕ-10.
"Ìåòà îãëÿäó" - êîä çã³äíî äîäàòêà N 5.
"Âèïàäîê" - êîä çã³äíî äîäàòêà N 6.
"Ïîïåðåäíÿ ãðóïà ³íâàë³äíîñò³" - ãðóïà ³íâàë³äíîñò³, ÿêà áóëà äî äàíîãî ïîâòîðíîãî îãëÿäó (âêàçàòè öèôðîþ).
"Âñòàíîâëåíà ãðóïà ³íâàë³äíîñò³" - âêàçàòè âñòàíîâëåíó ãðóïó ³íâàë³äíîñò³ àáî ëèñòîê íåïðàöåçäàòíîñò³, ÿêùî â³í ïðîäîâæåíèé. ßêùî ãðóïà ³íâàë³äíîñò³ íå âñòàíîâëåíà - ñòàâèòüñÿ ïðî÷åðê.
"Ñòðîê ³íâàë³äíîñò³" - âêàçàòè ñòðîê, íà ÿêèé âñòàíîâëåíà ³íâàë³äí³ñòü (ÿêùî áåçñòðîêîâî - á/ñ).
"̳ñöå îãëÿäó" - êîä çã³äíî äîäàòêà N 7.
"Ëèñòîê íåïðàöåçäàòíîñò³" - âêàçàòè ïðîäîâæåíî ÷è çàêðèòî.
"Âòðàòà ïðîôåñ³éíî¿ ïðàöåçäàòíîñò³" - âêàçàòè â³äñîòîê âòðàòè ïðîôåñ³éíî¿ ïðàöåçäàòíîñò³.
"Ïðè÷èíà ³íâàë³äíîñò³" - êîä çã³äíî äîäàòêà N 9 (îáîâ'ÿçêîâèé äëÿ ïåðâèííî âèçíàíèõ ³íâàë³äàìè).
"Ïîòðåáóº ë³êóâàííÿ" - êîä çã³äíî äîäàòêà N 11.
"Ïðàöåâëàøòîâàíèé" - âêàçàòè: ïðàöåâëàøòîâàíèé ³íâàë³ä ÷è í³.
"Ðåêîìåíäàö³¿" ïî ñîö³àëüíî-òðóäîâ³é ðåàá³ë³òàö³¿ - êîä çã³äíî äîäàòêà N 10.
Ñòàòèñòè÷íèé òàëîí ï³äïèñóº ãîëîâà ÌÑÅÊ.
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Êîä |
Íàéìåíóâàííÿ |
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1 |
Ðåñïóáë³êàíñüêà ÌÑÅÊ |
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2 |
Îáëàñíà ÌÑÅÊ |
|
3 |
Öåíòðàëüíà ì³ñüêà ÌÑÅÊ |
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4 |
̳æðàéîííà ÌÑÅÊ |
|
5 |
Êàðä³îëîã³÷íà ÌÑÅÊ |
|
6 |
Ôòèç³àòðè÷íà ÌÑÅÊ |
|
7 |
Ïñèõ³àòðè÷íà ÌÑÅÊ |
|
8 |
Îíêîëîã³÷íà ÌÑÅÊ |
|
9 |
Òðàâìàòîëîã³÷íà ÌÑÅÊ |
|
10 |
Ïðîôïàòîëîã³÷íà ÌÑÅÊ |
|
11 |
Òðàíñïîðòíà ÌÑÅÊ |
|
12 |
Ðàä³îëîã³÷íà ÌÑÅÊ |
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13 |
Íåâðî-íåéðîõ³ðóðã³÷íà ÌÑÅÊ |
|
14 |
Íåâðî-îôòàëüìîëîã³÷íà ÌÑÅÊ |
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15 |
Íåâðî-îôòàëüìî-ôòèç³àòðè÷íà ÌÑÅÊ |
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16 |
Êàðä³î-îôòàëüìîëîã³÷íà ÌÑÅÊ |
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17 |
Îôòàëüìî-íåâðîëîã³÷íà ÌÑÅÊ |
|
18 |
Íåéðî-îôòàëüìîëîã³÷íà ÌÑÅÊ |
|
19 |
Îôòàëüìî-òðàâìàòîëîã³÷íà ÌÑÅÊ |
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Êîä |
Íàéìåíóâàííÿ |
|
1 |
Ðîá³òíèê (âêëþ÷èòè âñ³ äåðæï³äïðèºìñòâà, óñòàíîâè, êîíöåðíè, àêö³îíåðí³ òîâàðèñòâà, ìàë³ ï³äïðèºìñòâà); |
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2 |
Ñëóæáîâåöü (âêëþ÷èòè âñ³ äåðæï³äïðèºìñòâà, óñòàíîâè, êîíöåðíè, àêö³îíåðí³ òîâàðèñòâà, ìàë³ ï³äïðèºìñòâà); |
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3 |
Êîëãîñïíèê; |
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4 |
Ôåðìåð, îðåíäàòîð; |
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5 |
²íäèâ³äóàëüíà òðóäîâà ä³ÿëüí³ñòü, ïðèâàòíå ï³äïðèºìíèöòâî; |
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6 |
³éñüêîâîñëóæáîâåöü; |
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7 |
Ïðàö³âíèê ÓÂÑ, ÑÁÓ, ïðîêóðàòóðè, ìèòíèö³; |
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8 |
Ó÷åíü; |
|
9 |
Ïåíñ³îíåð; |
|
10 |
Íå ïðàöþº; |
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11 |
²íâàë³ä ïðàö³ (çàãàëüíå çàõâîðþâàííÿ, òðóäîâå êàë³öòâî, ³íâàë³ä ç äèòèíñòâà); |
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12 |
²íâàë³ä â³éíè ³ ïðèð³âíåí³ äî ö³º¿ êàòåãî𳿠êîíòèíãåíòè |
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Êîä çà ÑÏÎÄÓ |
Íàçâà îá'ºêò³â äåðæàâíîãî, ãîñïîäàðñüêîãî òà ³íøèõ âèä³â óïðàâë³ííÿ |
|
1064 |
̳í³ñòåðñòâî àãðàðíî¿ ïîë³òèêè Óêðà¿íè |
|
1074 |
̳í³ñòåðñòâî åêîëî㳿 òà ïðèðîäíèõ ðåñóðñ³â Óêðà¿íè |
|
1084 |
̳í³ñòåðñòâî îñâ³òè ³ íàóêè Óêðà¿íè |
|
1094 |
̳í³ñòåðñòâî ïàëèâà òà åíåðãåòèêè Óêðà¿íè |
|
1104 |
Äåðæàâíèé êîì³òåò ³íôîðìàö³éíî¿ ïîë³òèêè, òåëåáà÷åííÿ òà ðàä³îìîâëåííÿ Óêðà¿íè |
|
1114 |
Äåðæàâíèé êîì³òåò ìîëîä³æíî¿ ïîë³òèêè, ñïîðòó ³ òóðèçìó Óêðà¿íè |
|
1124 |
Äåðæäåïàðòàìåíò íàôòîãàçïðîì |
|
1944 |
Äåðæêîìçâ'ÿçêó òà ³íôîðìàòèçàö³¿ |
|
3684 |
Êîðïîðàö³ÿ "Óêðòðàíñáóä" |
|
3704 |
Êîðïîðàö³ÿ "Óêðìîíòàæñïåöáóä" |
|
4084 |
̳íîáîðîíè |
|
4134 |
̳í³ñòåðñòâî ç ïèòàíü íàäçâè÷àéíèõ ñèòóàö³é òà ó ñïðàâàõ çàõèñòó íàñåëåííÿ â³ä íàñë³äê³â ×îðíîáèëüñüêî¿ êàòàñòðîôè |
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4754 |
Îðåíäí³ êîìåðö³éí³ ï³äïðèºìñòâà ³ îðãàí³çàö³¿ îðåíäàð³â (ñòâîðåí³ íà áàç³ äåðæï³äïðèºìñòâ) |
|
5054 - 5144 |
Äåðæàâí³, àêö³îíåðí³ òà êîìåðö³éí³ áàíêè |
|
6024 |
Àêö³îíåðí³ òîâàðèñòâà çàêðèòîãî òèïó (ñòâîðåí³ íà áàç³ äåðæï³äïðèºìñòâ) |
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6444 |
Ñåëÿíñüê³ (ôåðìåðñüê³) ãîñïîäàðñòâà |
|
6544 |
Äåðæêîì³òåò ïðîìèñëîâî¿ ïîë³òèêè |
|
6854 |
Óêðöåìåíò |
|
6894 |
Äåðæìèòñëóæáà |
|
7014 |
Óêðì³îöåâïðîì |
|
7064 |
Äåðæêîìë³ñãîñï |
|
7074 |
̳íïðàö³ ³ ñîö. ïîë³òèêè |
|
8084 |
Äåðæêîìáóä |
|
7154 |
Êîðïîðàö³ÿ "Óêðáóäìàòåð³àëè" |
|
7184 |
ÌÎÇ Óêðà¿íè |
|
7204 |
Óêðñîþçñåðâ³ñ |
|
7214 |
̳íòðàíñïîðòó |
|
7284 |
̳íô³íàíñ³â |
|
7294 |
̳íþñòèö³¿ |
|
7314 |
Äåðæàâíà ïîäàòêîâà àäì³í³ñòðàö³ÿ |
|
7724 |
ϳäïðèºìñòâà ç äåðæàâíîþ ÷àñòêîþ âëàñíîñò³ |
|
7734 |
Êîîïåðàòèâè Óêðà¿íè |
|
7744 |
Êîëåêòèâí³ ï³äïðèºìñòâà, çàñíîâàí³ íà âëàñíîñò³ òðóäîâîãî êîëåêòèâó |
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7774 |
ϳäïðèºìñòâà Óêðà¿íè, çàñíîâàí³ ô³çè÷íèìè îñîáàìè |
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8094 |
Äåðæêîì³òåò ïî âîäíîìó ãîñïîäàðñòâó |
|
8164 |
Êîðïîðàö³ÿ "Óêðàãðîïðîìáóä" |
|
8184 |
̳íåêîíîì³êè |
|
8354 |
̳í. âíóòð³øí³õ ñïðàâ |
|
8744 |
Äåðæäåïàðòàìåíò òðàêòîðíîãî ³ ñ³ëüñüêîãîñïîäàðñüêîãî ìàøèíîáóäóâàííÿ |
|
70924 |
Êîðïîðàö³ÿ "Óêðìåòðîòóíåëüáóä" |
|
|
²íø³ îá'ºêòè äåðæàâíîãî, ãîñïîäàðñüêîãî òà ³íøèõ âèä³â óïðàâë³ííÿ |
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Êîä |
Íàéìåíóâàííÿ |
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1 |
Àôãàíö³; |
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2 |
˳êâ³äàòîðè íàñë³äê³â ×ÀÅÑ; |
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3 |
Åâàêóéîâàí³ ³ç çîíè ×ÀÅÑ (30 êì çîíà); |
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4 |
Ïðîæèâàþ÷³ ³ ÿê³ ïðîæèâàëè â çîí³ ×ÀÅÑ (ïåðåñåëåíö³); |
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5 |
²íâàë³ä ÂÂâ; |
|
6 |
Ó÷àñíèê ÂÂâ |
|
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Êîä |
Íàéìåíóâàííÿ |
|
1 |
Âñòàíîâëåííÿ ãðóïè ³íâàë³äíîñò³; |
|
2 |
Âñòàíîâëåííÿ ãðóïè ï³ñëÿ ïðîäîâæåííÿ ëèñòêà íåïðàöåçäàòíîñò³; |
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3 |
Çì³íà ïðè÷èíè ³íâàë³äíîñò³; |
|
4 |
Âèçíà÷åííÿ â³äñîòê³â âòðàòè ïðàöåçäàòíîñò³; |
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5 |
Ïðîäîâæåííÿ ëèñòêà íåïðàöåçäàòíîñò³; |
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6 |
Îñêàðæåííÿ âèíåñåíèõ ð³øåíü (äëÿ îáëàñíèõ ÌÑÅÊ); |
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7 |
Êîíòðîëü âèíåñåíèõ ð³øåíü (äëÿ îáëàñíèõ ÌÑÅÊ); |
|
8 |
Î÷í³ êîíñóëüòàö³¿; |
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9 |
Âèçíà÷åííÿ ÷àñó íàñòàííÿ ³íâàë³äíîñò³; |
|
10 |
Âèçíà÷åííÿ ïîêàçàíü äëÿ çàáåçïå÷åííÿ àâòîìîá³ëåì; |
|
11 |
Âèçíà÷åííÿ ïîòðåáè â äîäàòêîâèõ âèäàõ äîïîìîãè, ï³ëüãàõ; |
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12 |
Âñòàíîâëåííÿ çâ'ÿçêó ïðè÷èíè ñìåðò³ ç ³íâàë³äí³ñòþ; |
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13 |
Ïåðåîãëÿä íà çì³íó ãðóïè ³íâàë³äíîñò³; |
|
14 |
Âèçíà÷åííÿ ïîêàçàíü äëÿ íàïðàâëåííÿ â áóäèíîê-³íòåðíàò; |
|
15 |
Âèçíà÷åííÿ òåõí³÷íèõ çàñîá³â ïðîòåçóâàííÿ; |
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16 |
²íø³ |
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Êîä |
Íàéìåíóâàííÿ |
|
1 |
Ïåðâèííèé |
|
2 |
Ïîâòîðíèé |
|
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Êîä |
Íàéìåíóâàííÿ |
|
1 |
ÌÑÅÊ |
|
2 |
Âè¿çä |
|
3 |
Ñòàö³îíàð |
|
4 |
Âäîìà |
|
|
Êîä |
Íàéìåíóâàííÿ |
|
1 |
Çàãàëüíå çàõâîðþâàííÿ |
|
2 |
Òðóäîâå êàë³öòâî |
|
3 |
Ïðîôåñ³éíå çàõâîðþâàííÿ |
|
4 |
²íâàë³äí³ñòü ç äèòèíñòâà |
|
5 |
²íâàë³äí³ñòü ç äèòèíñòâà (ïîðàíåííÿ, êîíòó糿, êàë³öòâî), ïîâ'ÿçàíà ç áîéîâèìè ä³ÿìè â ÂÂâ |
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6 |
Çàãàëüíå çàõâîðþâàííÿ, ïîâ'ÿçàíå ç ïåðåáóâàííÿì ó çîí³ ×ÀÅÑ (åâàêóéîâàí³ àáî îñîáè, ÿê³ ñàìîñò³éíî çàëèøèëè çîíó ðàä³îàêòèâíîãî çàáðóäíåííÿ) |
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7 |
Ïðîôåñ³éíå çàõâîðþâàííÿ, ïîâ'ÿçàíå ç âèêîíàííÿì ðîá³ò ïî ë³êâ³äàö³¿ íàñë³äê³â àâà𳿠íà ×ÀÅÑ |
|
8 |
Çàãàëüíå çàõâîðþâàííÿ, ïîâ'ÿçàíå ç âèêîíàííÿì ðîá³ò ïî ë³êâ³äàö³¿ íàñë³äê³â àâà𳿠íà ×ÀÅÑ |
|
9 |
Êàë³öòâî (çàõâîðþâàííÿ), îòðèìàíå ï³ä ÷àñ âèêîíàííÿ ñëóæáîâèõ îáîâ'ÿçê³â ïî ë³êâ³äàö³¿ íàñë³äê³â àâà𳿠íà ×ÀÅÑ |
|
10 |
Çàõâîðþâàííÿ, ïîâ'ÿçàíå ç 䳺þ ³îí³çóþ÷îãî âèïðîì³íþâàííÿ òà ³íøèõ øê³äëèâèõ ôàêòîð³â àâà𳿠íà ×ÀÅÑ (äëÿ îñ³á, ïðîæèâàþ÷èõ àáî ÿê³ ïðîæèâàëè íà òåðèòî𳿠ðàä³îàêòèâíîãî çàáðóäíåííÿ) |
|
11 |
Çàõâîðþâàííÿ, ïîâ'ÿçàíå ç íàñë³äêàìè àâà𳿠íà ×ÀÅÑ, ï³ä ÷àñ ïðîõîäæåííÿ â³éñüêîâî¿ ñëóæáè |
|
12 |
Çàõâîðþâàííÿ, ïîâ'ÿçàíå ç âèêîíàííÿì îáîâ'ÿçê³â â³éñüêîâî¿ ñëóæáè ïðè ë³êâ³äàö³¿ àâà𳿠íà ÿäåðíîìó îá'ºêò³ (×åëÿá³íñüê, Ñåìèïàëàòèíñüê) |
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13 |
Çàõâîðþâàííÿ, ïîâ'ÿçàíå ç 䳺þ ³îí³çóþ÷îãî âèïðîì³íþâàííÿ ïðè ³íøèõ ÿäåðíèõ âèïðîáóâàííÿõ |
|
14 |
Çàãàëüíå çàõâîðþâàííÿ, íå ïîâ'ÿçàíå ç 䳺þ øê³äëèâèõ ôàêòîð³â àâà𳿠íà ×ÀÅÑ |
|
15 |
Çàõâîðþâàííÿ (òðàâìà), ïîâ'ÿçàíà ç ðåïðåñ³ºþ |
|
16 |
Ïîðàíåííÿ (êîíòó糿, êàë³öòâî), îòðèìàíå ïðè çàõèñò³ ³ò÷èçíè |
|
17 |
Ïîðàíåííÿ (êîíòó糿, êàë³öòâî), îòðèìàíå ïðè âèêîíàíí³ îáîâ'ÿçê³â â³éñüêîâî¿ ñëóæáè |
|
18 |
Ïîðàíåííÿ (êîíòó糿, êàë³öòâî), îòðèìàíå ï³ä ÷àñ ïðîõîäæåííÿ â³éñüêîâî¿ ñëóæáè |
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19 |
Çàõâîðþâàííÿ, îòðèìàíå ï³ä ÷àñ ïðîõîäæåííÿ â³éñüêîâî¿ ñëóæáè |
|
20 |
Çàõâîðþâàííÿ, îòðèìàíå ïðè âèêîíàíí³ îáîâ'ÿçê³â â³éñüêîâî¿ ñëóæáè |
|
21 |
Çàõâîðþâàííÿ, ïîâ'ÿçàíå ç ïåðåáóâàííÿì íà ôðîíò³ |
|
22 |
Ïîðàíåííÿ (êîíòó糿, êàë³öòâî), îòðèìàíå ïðè âèêîíàíí³ ñëóæáîâèõ îáîâ'ÿçê³â |
|
23 |
Ïîðàíåííÿ, çàõâîðþâàííÿ, ïîâ'ÿçàí³ ç âèêîíàííÿì îáîâ'ÿçê³â â³éñüêîâî¿ ñëóæáè ïðè âèêîíàíí³ ³íòåðíàö³îíàëüíîãî îáîâ'ÿçêó (ÄÐÀ òà ³í.) |
|
24 |
Çàõâîðþâàííÿ âíàñë³äîê ïîðàíåííÿ â ïåð³îä áîéîâèõ ä³é ó ÂÂâ ³ ï³ñëÿ â³éíè |
|
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Êîä |
Íàéìåíóâàííÿ |
|
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Ìåäèêî-á³îëîã³÷í³ ôàêòîðè |
|
1 |
Âðîäæåíå çàõâîðþâàííÿ ³ âàäè ðîçâèòêó, ÿê³ ïåðåøêîäæàþòü àáî îáìåæóþòü ó÷àñòü â ñóñï³ëüíî-êîðèñí³é ïðàö³ |
|
2 |
Òÿæêå çàõâîðþâàííÿ ³ ïîøêîäæåííÿ, ÿê³ ïðèâîäÿòü äî ñò³éêî¿ âòðàòè ïðàöåçäàòíîñò³ |
|
3 |
Ðîçâèòîê òÿæêèõ ôóíêö³îíàëüíèõ ïîðóøåíü, ÿê³ ïåðåøêîäæàþòü âèêîíàííþ ïðîôåñ³éíèõ îáîâ'ÿçê³â (çíèæåííÿ ïðîôåñ³éíîñò³) |
|
4 |
Çíà÷íà òðèâàë³ñòü àêòèâíî¿ ôàçè àáî ÷àñò³ ðåöèäèâè õðîí³÷íîãî çàõâîðþâàííÿ |
|
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Ñîö³àëüíî-åêîíîì³÷í³ ôàêòîðè |
|
5 |
Íåñïðèÿòëèâ³ ôàêòîðè âèðîáíè÷îãî ñåðåäîâèùå, âíàñë³äîê ÿêîãî ç'ÿâèëîñü çàõâîðþâàííÿ (ïðîôçàõâîðþâàííÿ) |
|
6 |
 ì³ñöåâèõ óìîâàõ íåìຠðîáîòè, ÿêó ðåêîìåíäóº ÌÑÅÊ (áåç âòðàòè àáî çíà÷íîãî ïîíèæåííÿ ð³âíÿ êâàë³ô³êàö³¿) |
|
7 |
Íåìîæëèâ³ñòü ïåðåêâàë³ô³êàö³¿ ÷åðåç íèçüêèé ð³âåíü îñâ³òè |
|
8 |
³äñóòí³ñòü ìîæëèâîñòåé ïðàöåâëàøòóâàííÿ â çâ'ÿçêó ç 䳺þ íàêàçó ÌÎÇ ÑÐÑÐ N 100 |
|
9 |
Ñîö³àëüíî-ïîáóòîâ³ ôàêòîðè |
|
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Ôàêòîðè ÿêîñò³ ìåäè÷íî¿ ³ ñîö³àëüíî-òðóäîâî¿ ðåàá³ë³òàö³¿ |
|
10 |
ϳçíº âèÿâëåííÿ çàõâîðþâàíü âíàñë³äîê â³äñóòíîñò³ àáî ïîãàíî¿ ÿêîñò³ ïðîôîãëÿä³â ³ íåäîñòàòí³õ çíàíü ïî ðàíí³é ä³àãíîñòèö³ òà ³í. |
|
11 |
Íåäîë³êè êîíñåðâàòèâíîãî àáî îïåðàòèâíîãî ë³êóâàííÿ â ãîñòð³é ñòà䳿 õâîðîáè |
|
12 |
Íåäîë³êè â³äíîâíîãî ïåð³îäó ë³êóâàííÿ |
|
13 |
Íåäîë³êè â³ääàëåíîãî ïåð³îäó ë³êóâàííÿ (íåäîë³êè "Ä" ñïîñòåðåæåííÿ) |
|
14 |
Íåäîë³êè ó ïðàöåâëàøòóâàíí³ |
|
15 |
Íåäîòðèìàííÿ ³íñòðóêö³¿ ïî âñòàíîâëåííþ ãðóï ³íâàë³äíîñò³ |
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16 |
Àíàòîì³÷íèé äåôåêò |
|
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Êîä |
Íàéìåíóâàííÿ |
|
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Ðåêîìåíäàö³¿ ïî ïðàöåâëàøòóâàííþ: |
|
02 |
Ó çâè÷àéíèõ óìîâàõ âèðîáíèöòâà ç íàäàííÿì â³äïîâ³äíèõ óìîâ ïðàö³ |
|
03 |
Ó ñïåö³àëüíî ñòâîðåíèõ óìîâàõ ïðàö³ íà âèðîáíèöòâ³ |
|
04 |
Âäîìà |
|
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Ðåêîìåíäàö³¿ ïî ïðîôíàâ÷àííþ ³íâàë³ä³â: |
|
06 |
 óìîâàõ âèðîáíèöòâà |
|
07 |
Ñïåö³àë³çîâàí³ íàâ÷àëüí³ çàêëàäè-³íòåðíàòè äëÿ ä³òåé-³íâàë³ä³â ñèñòåìè ̳í³ñòåðñòâà ïðàö³ òà ñîö³àëüíî¿ ïîë³òèêè Óêðà¿íè |
|
08 |
Âèù³ òà ïðîôåñ³éíî-òåõí³÷í³ íàâ÷àëüí³ çàêëàäè I - II ð³âí³â àêðåäèòàö³¿ ̳íîñâ³òè Óêðà¿íè |
|
09 |
Âèù³ íàâ÷àëüí³ çàêëàäè III - IV ð³âí³â àêðåäèòàö³¿ ̳í³ñòåðñòâà îñâ³òè Óêðà¿íè |
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Ðåêîìåíäàö³¿ ïî òåõí³÷íèõ çàñîáàõ ðåàá³ë³òàö³¿: |
|
10 |
Íà ïðîòåçóâàííÿ |
|
11 |
Íà îòðèìàííÿ êð³ñëî-êîëÿñêè |
|
12 |
Íà îòðèìàííÿ àâòîìîá³ëÿ |
|
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Êîä |
Íàéìåíóâàííÿ |
|
0 |
Íå ïîòðåáóº |
|
1 |
Ñòàö³îíàð ÖÐË |
|
2 |
Îáëàñí³ öåíòðè |
|
3 |
ÍIJ |
|
4 |
Öåíòðè, â³ää³ëåííÿ ìåäè÷íî¿ ðåàá³ë³òàö³¿ |
|
5 |
Ñàí³òàðíî-êóðîðòíå ë³êóâàííÿ |
|
6 |
Àìáóëàòîðíå ë³êóâàííÿ |
|
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Êîä |
Íàéìåíóâàííÿ |
|
1 |
˳êàð |
|
2 |
Ìåäñåñòðà (ôåëüäøåð) |
|
3 |
Ìîëîäøèé ìåäè÷íèé ïåðñîíàë |
|
4 |
Àäì³í³ñòðàòèâíî-ãîñïîäàðñüêèé ñëóæáîâåöü |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
|
Ìåäè÷íà äîêóìåíòàö³ÿ |
|
Íàéìåíóâàííÿ çàêëàäó | ||
|
ÑÒÀÒÈÑÒÈ×ÍÈÉ ÒÀËÎÍ N 2 Àêò N ____________________________________________________ (4) ________________________________________________________ (1, 2) __________________________________________________________ (3) __________________________________________________________ (5) __________________________________________________________ (6) __________________________________________________________ (7) __________________________________________________________ (8) __________________________________________________________ (9) _________________________________________________________ (10) _________________________________________________________ (11) _________________________________________________________ (15) Ìåäè÷í³ ïîêàçàííÿ íà çàáåçïå÷åííÿ ______________________________________________, ïåðåäáà÷åí³ ïóíêòîì _______ Ïåðåë³êó ìåäè÷íèõ ïîêàçàíü íà ïðàâî Ìåäè÷í³ ïðîòèïîêàçàííÿ äî êåðóâàííÿ _________________________________________________ ³äïîâ³äíî äî ïóíêòó ______ Ïåðåë³êó çàõâîðþâàíü ³ âàä, ïðè ÿêèõ ³íâàë³ä íå ìîæå áóòè äîïóùåíèé äî êåðóâàííÿ àâòîìîá³ëåì, çàòâåðäæåíîãî ̳í³ñòåðñòâîì îõîðîíè çäîðîâ'ÿ ______ 20 ðîêó (16.3) Ãîëîâà ÌÑÅÊ _____________________ ( ) | ||
|
Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
|
̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
|
Ìåäè÷íà äîêóìåíòàö³ÿ |
|
Íàéìåíóâàííÿ çàêëàäó |
²ÍÄȲÄÓÀËÜÍÀ ÏÐÎÃÐÀÌÀ
ÐÅÀÁ²Ë²ÒÀÖ²¯ ²ÍÂÀ˲ÄÀ
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
|
Ìåäè÷íà äîêóìåíòàö³ÿ | |
|
Íàéìåíóâàííÿ çàêëàäó | |||
|
ÆÓÐÍÀË Ïî÷àòî "____" ___________ 20__ ð. Çàê³í÷åíî "____" _________ 20__ ð. | |||
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| |||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 160-1/î
|
N |
Ïð³çâèùå, ³ì'ÿ, ïî |
Äàòà |
Íàïðàâëåííÿ ²ÏÐ |
Âèäàíî |
Ðîçïèñêà â | |
|
íàçâà îðãàíó, |
äàòà | |||||
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1 |
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7 |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
|
Ìåäè÷íà äîêóìåíòàö³ÿ | |
|
Íàéìåíóâàííÿ çàêëàäó | |||
|
ÆÓÐÍÀË Ïî÷àòî "____" ___________ 20__ ð. Çàê³í÷åíî "____" __________ 20__ ð. | |||
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| |||
|
Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 160-2/î
|
Îòðèìàííÿ | |||
|
Äàòà îòðèìàííÿ |
Íàéìåíóâàííÿ ³ íîìåð |
Ñåð³ÿ ³ íîìåðè áëàíê³â |
ʳëüê³ñòü |
|
1 |
2 |
3 |
4 |
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ñòîð. 3 ô. N 160-2/î
|
Âèòðàòà | ||||
|
Äàòà |
Íàéìåíóâàííÿ ³ íîìåð |
ʳëüê³ñòü |
Ñåð³ÿ ³ íîìåðè |
Çàëèøîê |
|
5 |
6 |
7 |
8 |
9 |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
|
Ìåäè÷íà äîêóìåíòàö³ÿ |
|
Íàéìåíóâàííÿ çàêëàäó | ||
|
N _______________________ ÌÅÄÅÊÑÏÅÐÒÍÀ
ÑÏÐÀÂÀ _________________________________________________________ _________________________________________________________ Àäðåñà _______________________________________________________ Äèíàì³êà ³íâàë³äíîñò³
| ||
ñòîð. 2 ô. N 160-3/î
|
Òðóäîâà ä³ÿëüí³ñòü â õðîíîëîã³÷íîìó ïîðÿäêó | |||
|
Äàòà âñòàíîâëåííÿ ³íâàë³äíîñò³ |
ϳñëÿ âñòàíîâëåííÿ ³íâàë³äíîñò³ | ||
|
Äàòà |
Êèì ïðàöþâàâ |
Äàòà |
Êèì ïðàöþâàâ |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
|
Ìåäè÷íà äîêóìåíòàö³ÿ | |
|
Íàéìåíóâàííÿ çàêëàäó | |||
|
ÆÓÐÍÀË ÊÎÍÒÐÎËÞ ÂÈÊÎÍÀÍÍß ²ÍÄȲÄÓÀËÜÍÈÕ ÏÐÎÃÐÀÌ ÐÅÀÁ²Ë²ÒÀÖ²¯ ²ÍÂÀ˲IJ Ïî÷àòî "_____" ___________________ 20__ ð. Çàê³í÷åíî "_____" ___________________ 20__ ð. | |||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 160-4/î
|
N |
Äàòà |
Ïð³çâèùå, ³ì'ÿ, |
Äîìàøíÿ |
Îñâ³òà, |
Ãðóïà, |
ijàãíîç |
Ìåäè÷íà ðåàá³ë³òàö³ÿ | ||||
|
Âèäè |
Äàòè |
Ðåçóëüòàòè | |||||||||
|
ñòàö., àìá., |
ïëàíîâ. |
ïðîâåäåíèé |
âèêîíàíî |
íå âèêîíàíî | |||||||
|
1 |
2 |
3 |
4 |
5 |
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8 |
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ñòîð. 3 ô. N 160-4/î
|
Ñîö³àëüíî-òðóäîâà (ïîáóòîâà) |
Ïðîôåñ³éíà ðåàá³ë³òàö³ÿ |
Äèíàì³êà ³íâàë³äíîñò³ | |||||||||
|
Âèäè |
Ðåçóëüòàò |
Çã³äíî |
Äàòè êîíòðîëþ |
Ðåçóëüòàòè |
Ðîêè | ||||||
|
Ïëàíîâ. |
ïðîâåäåíèé |
âèêîíàíî |
íå âèêîíàíî |
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13 |
14 |
15 |
16 |
17 |
18 |
19 |
20 | ||||
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ | |
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Íàéìåíóâàííÿ çàêëàäó | |||
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ÍÀÏÐÀÂËÅÍÍß Âèäàíå ãð. ___________________________________________________________________________ _____________________________________________________________________________________ Äàòà íàðîäæåííÿ 1.  ë³êóâàëüíî-ïðîô³ëàêòè÷í³ çàêëàäè íà:
2.  ³íø³ îðãàíè òà óñòàíîâè ____________________________________________________________ Ì. Ï. Ãîëîâà ÌÑÅÊ ______________________________ | |||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
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Ïðèì³òêà. |
Áëàíê "Íàïðàâëåííÿ" ïðèçíà÷åíèé äëÿ íàïðàâëåííÿ õâîðîãî â ë³êóâàëüíî-ïðîô³ëàêòè÷í³ çàêëàäè òà ³íø³ îðãàíè òà óñòàíîâè íà êîíñóëüòàö³þ, ãîñï³òàë³çàö³þ, äîîáñòåæåííÿ ç ìåòîþ óòî÷íåííÿ ä³àãíîçó, ñòóïåíÿ ôóíêö³îíàëüíèõ ïîðóøåíü, ïîäàëüøîãî ïðîãíîçó òà ë³êóâàííÿ. |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ |
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Íàéìåíóâàííÿ çàêëàäó | ||
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________________________________________________________ ________________________________________________________ ÏβÄÎÌËÅÍÍß Ï²ÄÏÐȪÌÑÒÂÓ, ÓÑÒÀÍβ, ÎÐÃÀͲÇÀÖ²¯ ________________________________________________________ Äàòà íàðîäæåííÿ Äàòà îãëÿäó Îãëÿä __________________________________________________ Ãðóïà ³íâàë³äíîñò³ ________________________________________ Ïðè÷èíà ³íâàë³äíîñò³ _____________________________________ ²íâàë³äí³ñòü âñòàíîâëåíà íà ñòðîê äî 1 ____________ 20__ ð. Äàòà ÷åðãîâîãî ïåðåîãëÿäó | ||
ñòîð. 2 ô. N 162/î
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ÂÈÑÍÎÂÎÊ ÏÐÎ ÓÌÎÂÈ ÒÀ ÕÀÐÀÊÒÅÐ ÏÐÀÖ² ________________________________________________________ Ðåêîìåíäîâàí³ çàõîäè ïî â³äíîâëåííþ ïðàöåçäàòíîñò³ ________________________________________________________ ϳäñòàâà: àêò N ___________ îãëÿäó ÌÑÅÊ ___________________ Äàòà Ì. Ï. Ãîëîâà ÌÑÅÊ __________________ (____________) |
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
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Ïðèì³òêà. |
Öåé áëàíê ïðèçíà÷åíèé äëÿ ïîâ³äîìëåííÿ ï³äïðèºìñòâó, óñòàíîâ³ ÷è îðãàí³çàö³¿ ïðî ðåçóëüòàòè îãëÿäó ÌÑÅÊ, ïðî ðåêîìåíäîâàí³ çàõîäè ïî â³äíîâëåííþ ïðàöåçäàòíîñò³ ³ íàïðàâëÿºòüñÿ çà ì³ñöåì ðîáîòè îãëÿíóòîãî. |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ | |||||
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Íàéìåíóâàííÿ çàêëàäó | |||||||
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ÆÓÐÍÀË Ïî÷àòî "____" ___________ 20__ ð. Çàê³í÷åíî "____" __________ 20__ ð. | |||||||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 163/î
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N |
Ïð³çâèùå, ³ì'ÿ, ïî |
Äàòà íàäõîäæåííÿ |
Õòî |
Ç ÿêî¿ ÌÑÅÊ |
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ñòîð. 3 ô. N 163/î
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Ïî ÿêîìó |
Äàòà òà ðåçóëüòàò ðîçãëÿäó |
Êóäè ïåðåäàí³ |
Äàòà |
Ïðèì³òêà |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ | |
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Íàéìåíóâàííÿ çàêëàäó | |||
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ÆÓÐÍÀË Ïî÷àòî "____" ___________ 20__ ð. Çàê³í÷åíî "____" __________ 20__ ð. | |||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 163-1/î
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N |
Ïð³çâèùå, ³ì'ÿ, ïî |
Äàòà |
Êîìó, êóäè |
ϳäïèñ |
Äàòà |
ϳäïèñ |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ | |
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Íàéìåíóâàííÿ çàêëàäó | |||
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ÆÓÐÍÀË Ïî÷àòî "____" ___________ 20__ ð. Çàê³í÷åíî "____" ___________ 20__ ð. | |||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 164/î
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N |
Äàòà |
Ïð³çâèùå, ³ì'ÿ, ïî |
гê |
Ìåòà êîíñóëüòàö³¿ |
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ñòîð. 3 ô. N 164/î
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Õòî íàïðàâëÿº |
Âèñíîâîê îãëÿäó ÌÑÅÊ |
Ïðèì³òêà |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ | |
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Íàéìåíóâàííÿ çàêëàäó | |||
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ÆÓÐÍÀË Ïî÷àòî "____" ___________ 20__ ð. Çàê³í÷åíî "____" __________ 20__ ð. | |||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 164-1/î
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N |
Äàòà âèäà÷³ |
Ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ |
гøåííÿ |
Ìåòà |
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ñòîð. 3 ô. N 164-1/î
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Äàòà |
ÓêðÄåðæÍIJ ÌÑϲ, |
Âèñíîâîê |
Ïðè÷èíà ðîçõîäæåííÿ |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ | |
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Íàéìåíóâàííÿ çàêëàäó | |||
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ÆÓÐÍÀË Ïî÷àòî "____" ___________ 20__ ð. Çàê³í÷åíî "____" __________ 20__ ð. | |||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 164-2/î
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N |
Äàòà |
Ïð³çâèùå, ³ì'ÿ, ïî |
Äîìàøíÿ àäðåñà |
Ïðè÷èíà çâåðíåííÿ |
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ñòîð. 3 ô. N 164-2/î
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Âèêîíàâåöü |
Ðåçóëüòàòè ðîçãëÿäó |
Õàðàêòåðèñòèêà çâåðíåíü | ||||
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ïåðâèííî |
ïîâòîðíî |
çàÿâà |
ñêàðãà |
ïðîïîçèö³ÿ | ||
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ | |
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Íàéìåíóâàííÿ çàêëàäó | |||
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ÆÓÐÍÀË Ïî÷àòî "____" ___________ 20__ ð. Çàê³í÷åíî "____" __________ 20__ ð. | |||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 165/î
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N |
Äàòà |
Ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ |
Íàçâà ë³êóâàëüíîãî |
Ìåòà |
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ñòîð. 3 ô. N 165/î
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Ïåðâèííî íà |
Äåôåêòè â îôîðìëåíí³ |
Äàòà |
Äàòà |
²ÂÂ, ²ÐÀ |
Äàòà |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ | |
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Íàéìåíóâàííÿ çàêëàäó | |||
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ÆÓÐÍÀË Ïî÷àòî "____" ___________ 20__ ð. Çàê³í÷åíî "____" __________ 20__ ð. | |||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
ñòîð. 2 ô. N 166/î
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N |
Äàòà |
Ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ |
Íàçâà ë³êóâàëüíîãî |
ijàãíîç ë³êóâàëüíîãî |
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ñòîð. 3 ô. N 166/î
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Äàòà îãëÿäó |
Ñòðîê òèì÷àñ. |
гøåííÿ ÌÑÅÊ |
Ïðè÷èíà âñòàíîâëåííÿ |
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̳í³ñòåðñòâî îõîðîíè çäîðîâ'ÿ Óêðà¿íè |
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Ìåäè÷íà äîêóìåíòàö³ÿ |
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Íàéìåíóâàííÿ çàêëàäó | ||
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ÄβÄÊÀ Âèäàíà ãð. ______________________________________________ Äàòà íàðîäæåííÿ Äîìàøíÿ àäðåñà _________________________________________ â òîìó, ùî â³í (âîíà) îãëÿäàâñÿ(ëàñü) ________________________________________________________ ³ çà ðåçóëüòàòàìè íå âèçíàíèé(àíà) ³íâàë³äîì Ì. Ï. ÌÑÅÊ Ãîëîâà ÌÑÅÊ ____________________ (_____________) | ||
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Äëÿ äðóêàðí³! Ïðè âèãîòîâëåíí³ äîêóìåíòà |
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