DECLARACION DE INCIDENTE

Declaración del Trabajador

NOMBRE DEL TRABAJADOR INVOLUCRADO: ___________________________________________

LUGAR DEL ACCIDENTE/INCIDENTE: __________________________________________________

FECHA: ____/_____/_____ HORA: _______________

DESCRIPCION DE LO ACONTECIDO:

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Nombre Completo:
Rut:
Cargo:
Fecha:

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Firma y Huella Dactilar