NOTIFICAO DE SEGURANA DO TRABALHO

Erresa:

Setcr:

hcre Jc ErreaJc (a):

lurac:


Data Ja 0ccrrercia:_____/_____/_____ as _____:_____ |cras

Ocrfcrre artic I5& Ja lei r c5I+ Je ZZ.IZ.IJII e iter I.&.I Ja hcrra ReularertaJcra r I Ja
Pcrtaria JZI+ Je J&.Jc.IJI& Jc Niristeric Jc Tra|al|c, fica 1cssa essca h0TlllOAD0(A) cr ter
irccrriJc er atc faltcsc cr:

lalta Jc Usc Jc 0culcs Je Prcteac lalta Jc Usc Jc Oirtc Je Seurara
lalta Jc Usc Jc Oaacete Estar ser urifcrre ccrletc
lalta Jc Usc Jc Prctetcr AuJiti1c SclJar/Ocrtar ser autcri/aac
lalta Jc Usc Je ResiraJcr lirar c ccrc ccr ar rarJaJc
SclJar ser EPls: a1ertal, erreira, rarcte, rascara, lu1a Je rasa,
Narusear rcJutcs uiriccs ser EPls: a1ertal, lu1as, |cta 1c, cculcs, rascara seri facial.
0utrc:
0BS: latc reserciaJc elc Tecricc Je Seurara Jc Tra|al|c er Jata e |craric acira.

DEOlARAA0
Declarc rece|er a reserte rctificaac, ccrc aJ1ertercia elc Atc laltcsc Jescritc acira, Je ter
rece|iJc irstruces Ja Erresa rc sertiJc Je rac irccrrer er rc1as fal|as, |er ccrc ter siJc
esclareciJc sc|re as eraliJaJes alica1eis ara tais cascs, ccrfcrre leislaac er 1icr.



Assiratura Jc lrfratcr Assiratura Jc Rescrsa1el c|efe Jc setcr

Assiratura e Oarir|c Jc Tecricc Je Seurara.