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Образец (Примерный). Форма личной медицинской книжки для работников отдельных профессий, производств и организаций, деятельность котор

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11.04.2007 г.
Образец (Примерный). Форма личной медицинской книжки для работников отдельных профессий, 
производств и организаций, деятельность которых связана с производством, хранением, 
транспортировкой и реализацией пищевых продуктов и питьевой воды, воспитанием и обучением 
детей, коммунальным и бытовым обслуживанием населения

Приложение N 1    
   Утверждено
   Приказ Федеральной службы
   по надзору в сфере защиты прав
   потребителей и благополучия
   человека
   от 20.05.2005 N 402
   
   ------------------------------------------------------------------
   ¦                                                                ¦
   ¦                                             ЛИЧНАЯ             ¦
   ¦                                          МЕДИЦИНСКАЯ           ¦
   ¦                                             КНИЖКА             ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                        Федеральная служба      ¦
   ¦                                    по надзору в сфере защиты   ¦
   ¦                                         прав потребителей      ¦
   ¦                                     и благополучия человека    ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ------------------------------------------------------------------
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦ -----------                                 ЛИЧНАЯ           О ¦
   ¦ ¦         ¦                              МЕДИЦИНСКАЯ         С ¦
   ¦ ¦         ¦                                 КНИЖКА           П ¦
   ¦ ¦         ¦                                                  О ¦
   ¦ ¦         ¦                                                  Т ¦
   ¦ -----------                                                  Р ¦
   ¦    (код                            Выдается       работникам Е ¦
   ¦   региона)                     производств   и   организаций Б ¦
   ¦                                (индивидуальным               Н ¦
   ¦                                предпринимателям),            А ¦
   ¦                                деятельность которых связана  Д ¦
   ¦                                с производством,  хранением,  З ¦
   ¦                                транспортировкой           и  О ¦
   ¦                                реализацией          пищевых  Р ¦
   ¦                                продуктов и питьевой   воды,    ¦
   ¦                                воспитанием   и   обучением     ¦
   ¦                                детей,    коммунальным    и     ¦
   ¦                                бытовым       обслуживанием     ¦
   ¦                                населения                       ¦
   ¦                                                                ¦
   ¦                                            N 0000000           ¦
   ------------------------------------------------------------------
   
   ------------------------------------------------------------------
   ¦  2 ¦                                                           ¦
   +-----                                          ---------------- ¦
   ¦                                     ----------+--            ¦ ¦
   ¦     Федеральная служба по надзору   ¦         ¦ ¦ Место под  ¦ ¦
   ¦   в сфере защиты прав потребителей  ¦         ¦ ¦  круглую   ¦ ¦
   ¦        и благополучия человека      ¦         ¦ ¦ голограмму ¦ ¦
   ¦                                     ¦         ¦ ¦            ¦ ¦
   ¦                                     ¦         --+------------- ¦
   ¦                                     ¦           ¦              ¦
   ¦                                     ¦           ¦              ¦
   ¦                                     ¦           ¦              ¦
   ¦                                     -------------              ¦
   ¦                                                 М.П.           ¦
   ¦                                                                ¦
   ¦   Личная медицинская книжка выдана _________________________   ¦
   ¦                                          (наименование         ¦
   ¦                                           организации          ¦
   ¦                                        Роспотребнадзора,       ¦
   ¦   __________________________________________________________   ¦
   ¦                   выдавшей медицинскую книжку)                 ¦
   ¦                                                                ¦
   ¦   Подпись руководителя ___________   _______________________   ¦
   ¦                                       (Ф.И.О. руководителя)    ¦
   ¦                                                                ¦
   ¦   Дата выдачи ______________                                   ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦   Сведения о владельце медицинской книжки:                     ¦
   ¦N                                                               ¦
   ¦   Фамилия __________________________________________________   ¦
   ¦0  Имя, отчество ____________________________________________   ¦
   ¦0  Год рождения _____________________________________________   ¦
   ¦0  Домашний адрес ___________________________________________   ¦
   ¦0  __________________________________________________________   ¦
   ¦0  Должность ______________________   _______________________   ¦
   ¦0                                         (личная подпись)      ¦
   ¦0                                                               ¦
   ¦   Организация (индивидуальный предприниматель) _____________   ¦
   ¦   __________________________________________________________   ¦
   ¦                                                                ¦
   +-----                                                           ¦
   ¦  3 ¦                                         РОСПОТРЕБНАДЗОР   ¦
   -----+------------------------------------------------------------
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦  II. Отметки о переходе на      III. Отметки о перенесенных  О ¦
   ¦  работу в другие организации     инфекционных заболеваниях   С ¦
   ¦                                                              П ¦
   ¦ -----------------------------   ---------------------------- О ¦
   ¦ ¦Дата¦Наимено-¦Долж-¦Подпись¦   ¦Дата¦  Диагноз  ¦Подпись, ¦ Т ¦
   ¦ ¦    ¦вание   ¦ность¦       ¦   ¦    ¦           ¦ печать  ¦ Р ¦
   ¦ ¦    ¦органи- ¦     ¦       ¦   ¦    ¦           ¦         ¦ Е ¦
   ¦ ¦    ¦зации   ¦     ¦       ¦   ¦    ¦           ¦         ¦ Б ¦
   ¦ ¦    ¦(индиви-¦     ¦       ¦   ¦    ¦           ¦         ¦ Н ¦
   ¦ ¦    ¦дуально-¦     ¦       ¦   ¦    ¦           ¦         ¦ А ¦
   ¦ ¦    ¦го пред-¦     ¦       ¦   ¦    ¦           ¦         ¦ Д ¦
   ¦ ¦    ¦прини-  ¦     ¦       ¦   ¦    ¦           ¦         ¦ З ¦
   ¦ ¦    ¦мателя) ¦     ¦       ¦   ¦    ¦           ¦         ¦ О ¦
   ¦ +----+--------+-----+-------+   +----+-----------+---------+ Р ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   ¦    ¦           ¦         ¦   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   +----+-----------+---------+   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   ¦    ¦           ¦         ¦   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   +----+-----------+---------+   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   ¦    ¦           ¦         ¦   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   +----+-----------+---------+   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   ¦    ¦           ¦         ¦   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   +----+-----------+---------+   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   ¦    ¦           ¦         ¦   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   +----+-----------+---------+   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   ¦    ¦           ¦         ¦   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   +----+-----------+---------+   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   ¦    ¦           ¦         ¦   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   +----+-----------+---------+   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ +----+--------+-----+-------+   ¦    ¦           ¦         ¦   ¦
   ¦ ¦    ¦        ¦     ¦       ¦   ¦    ¦           ¦         ¦   ¦
   ¦ -----+--------+-----+--------   -----+-----------+----------   ¦
   ¦                                                                ¦
   +-----                                  N 0000000           -----+
   ¦  4 ¦                                                      ¦  5 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦ IV. Отметки о профилактических     V. Заключение врача о     О ¦
   ¦           прививках                  допуске к работе по     С ¦
   ¦                                    результатам медицинского  П ¦
   ¦                                         обследования         О ¦
   ¦                                                              Т ¦
   ¦ -----------------------------   ---------------------------- Р ¦
   ¦ ¦Дата¦Наимено- ¦  Подпись,  ¦   ¦Дата¦Заключение¦Ф.И.О.,   ¦ Е ¦
   ¦ ¦    ¦вание    ¦   печать   ¦   ¦    ¦  врача   ¦подпись и ¦ Б ¦
   ¦ ¦    ¦прививки ¦            ¦   ¦    ¦          ¦личная пе-¦ Н ¦
   ¦ ¦    ¦(вакци-  ¦            ¦   ¦    ¦          ¦чать врача¦ А ¦
   ¦ ¦    ¦нация и  ¦            ¦   ¦    ¦          ¦          ¦ Д ¦
   ¦ ¦    ¦ревакци- ¦            ¦   ¦    ¦          ¦          ¦ З ¦
   ¦ ¦    ¦нация)   ¦            ¦   ¦    ¦          ¦          ¦ О ¦
   ¦ +----+---------+------------+   +----+----------+----------+ Р ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +---------+            ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+---------+------------+   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +---------+            ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+---------+------------+   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +---------+            ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+---------+------------+   +----+----------+----------+   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +---------+            ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+---------+------------+   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +---------+            ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+---------+------------+   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +---------+            ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+---------+------------+   +----+----------+----------+   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +---------+            ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+---------+------------+   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +---------+            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    ¦         ¦            ¦   ¦    ¦          ¦          ¦   ¦
   ¦ -----+---------+-------------   -----+----------+-----------   ¦
   ¦                                                                ¦
   +-----                                  N 0000000           -----+
   ¦  6 ¦                                                      ¦  7 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦ V. Заключение врача о допуске      V. Заключение врача о     О ¦
   ¦     к работе по результатам          допуске к работе по     С ¦
   ¦    медицинского обследования       результатам медицинского  П ¦
   ¦                                         обследования         О ¦
   ¦                                                              Т ¦
   ¦ -----------------------------   ---------------------------- Р ¦
   ¦ ¦Дата¦Заключение¦Ф.И.О.,    ¦   ¦Дата¦Заключение¦Ф.И.О.,   ¦ Е ¦
   ¦ ¦    ¦  врача   ¦подпись и  ¦   ¦    ¦  врача   ¦подпись и ¦ Б ¦
   ¦ ¦    ¦          ¦личная пе- ¦   ¦    ¦          ¦личная пе-¦ Н ¦
   ¦ ¦    ¦          ¦чать врача ¦   ¦    ¦          ¦чать врача¦ А ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ Д ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ З ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ О ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ Р ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ -----+----------+------------   -----+----------+-----------   ¦
   ¦                                                                ¦
   +-----                                  N 0000000           -----+
   ¦  8 ¦                                                      ¦  9 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦ V. Заключение врача о допуске      V. Заключение врача о     О ¦
   ¦     к работе по результатам          допуске к работе по     С ¦
   ¦    медицинского обследования       результатам медицинского  П ¦
   ¦                                         обследования         О ¦
   ¦                                                              Т ¦
   ¦ -----------------------------   ---------------------------- Р ¦
   ¦ ¦Дата¦Заключение¦Ф.И.О.,    ¦   ¦Дата¦Заключение¦Ф.И.О.,   ¦ Е ¦
   ¦ ¦    ¦  врача   ¦подпись и  ¦   ¦    ¦  врача   ¦подпись и ¦ Б ¦
   ¦ ¦    ¦          ¦личная пе- ¦   ¦    ¦          ¦личная пе-¦ Н ¦
   ¦ ¦    ¦          ¦чать врача ¦   ¦    ¦          ¦чать врача¦ А ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ Д ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ З ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ О ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ Р ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ -----+----------+------------   -----+----------+-----------   ¦
   ¦                                                                ¦
   +-----                                  N 0000000           -----+
   ¦ 10 ¦                                                      ¦ 11 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦ V. Заключение врача о допуске      V. Заключение врача о     О ¦
   ¦     к работе по результатам          допуске к работе по     С ¦
   ¦    медицинского обследования       результатам медицинского  П ¦
   ¦                                         обследования         О ¦
   ¦                                                              Т ¦
   ¦ -----------------------------   ---------------------------- Р ¦
   ¦ ¦Дата¦Заключение¦Ф.И.О.,    ¦   ¦Дата¦Заключение¦Ф.И.О.,   ¦ Е ¦
   ¦ ¦    ¦  врача   ¦подпись и  ¦   ¦    ¦  врача   ¦подпись и ¦ Б ¦
   ¦ ¦    ¦          ¦личная пе- ¦   ¦    ¦          ¦личная пе-¦ Н ¦
   ¦ ¦    ¦          ¦чать врача ¦   ¦    ¦          ¦чать врача¦ А ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ Д ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ З ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ О ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ Р ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ -----+----------+------------   -----+----------+-----------   ¦
   ¦                                                                ¦
   +-----                                  N 0000000           -----+
   ¦ 12 ¦                                                      ¦ 13 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦ V. Заключение врача о допуске      V. Заключение врача о     О ¦
   ¦     к работе по результатам          допуске к работе по     С ¦
   ¦    медицинского обследования       результатам медицинского  П ¦
   ¦                                         обследования         О ¦
   ¦                                                              Т ¦
   ¦ -----------------------------   ---------------------------- Р ¦
   ¦ ¦Дата¦Заключение¦Ф.И.О.,    ¦   ¦Дата¦Заключение¦Ф.И.О.,   ¦ Е ¦
   ¦ ¦    ¦  врача   ¦подпись и  ¦   ¦    ¦  врача   ¦подпись и ¦ Б ¦
   ¦ ¦    ¦          ¦личная пе- ¦   ¦    ¦          ¦личная пе-¦ Н ¦
   ¦ ¦    ¦          ¦чать врача ¦   ¦    ¦          ¦чать врача¦ А ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ Д ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ З ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ О ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ Р ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   ¦    +----------+          ¦   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ -----+----------+------------   -----+----------+-----------   ¦
   ¦                                                                ¦
   +-----                                  N 0000000           -----+
   ¦ 14 ¦                                                      ¦ 15 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦ V. Заключение врача о допуске           VI. Результаты       О ¦
   ¦     к работе по результатам       обследования на туберкулез С ¦
   ¦    медицинского обследования                                 П ¦
   ¦                                                              О ¦
   ¦ -----------------------------   ---------------------------- Т ¦
   ¦ ¦Дата¦Заключение¦Ф.И.О.,    ¦   ¦Дата¦Заключение¦ Подпись, ¦ Р ¦
   ¦ ¦    ¦  врача   ¦подпись и  ¦   ¦    ¦лаборато- ¦  печать  ¦ Е ¦
   ¦ ¦    ¦          ¦личная пе- ¦   ¦    ¦рии       ¦ (штамп)  ¦ Б ¦
   ¦ ¦    ¦          ¦чать врача ¦   ¦    ¦          ¦          ¦ Н ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ А ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ Д ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+ З ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ О ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+ Р ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ -----+----------+------------   -----+----------+-----------   ¦
   ¦                                                                ¦
   +-----                                                      -----+
   ¦ 16 ¦                                                      ¦ 17 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦  VI. Результаты обследования    VII. Результаты исследования О ¦
   ¦         на туберкулез           на носительство возбудителей С ¦
   ¦                                     кишечных инфекционных    П ¦
   ¦                                          заболеваний         О ¦
   ¦                                                              Т ¦
   ¦ -----------------------------   ---------------------------- Р ¦
   ¦ ¦Дата¦Заключение¦  Подпись, ¦   ¦Дата¦Заключение¦Ф.И.О.,   ¦ Е ¦
   ¦ ¦    ¦лаборато- ¦   печать  ¦   ¦    ¦  врача   ¦подпись и ¦ Б ¦
   ¦ ¦    ¦рии       ¦  (штамп)  ¦   ¦    ¦          ¦личная пе-¦ Н ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦чать врача¦ А ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ Д ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ З ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ О ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ Р ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ -----+----------+------------   -----+----------+-----------   ¦
   ¦                                                                ¦
   +-----                                                      -----+
   ¦ 18 ¦                                                      ¦ 19 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦  VII. Результаты исследования         VIII. Результаты       О ¦
   ¦  на носительство возбудителей    лабораторных исследований   С ¦
   ¦      кишечных инфекционных      и осмотра дерматовенеролога  П ¦
   ¦         заболеваний                                          О ¦
   ¦                                                              Т ¦
   ¦ -----------------------------   ---------------------------- Р ¦
   ¦ ¦Дата¦Заключение¦  Подпись, ¦   ¦Дата¦Заключение¦Ф.И.О.,   ¦ Е ¦
   ¦ ¦    ¦лаборато- ¦   печать  ¦   ¦    ¦  врача   ¦подпись и ¦ Б ¦
   ¦ ¦    ¦рии       ¦  (штамп)  ¦   ¦    ¦          ¦личная пе-¦ Н ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦чать врача¦ А ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ Д ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ З ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ О ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ Р ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ -----+----------+------------   -----+----------+-----------   ¦
   ¦                                                                ¦
   +-----                                                      -----+
   ¦ 20 ¦                                                      ¦ 21 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦ VIII. Результаты лабораторных         VIII. Результаты       О ¦
   ¦      исследований и осмотра      лабораторных исследований   С ¦
   ¦         дерматовенеролога       и осмотра дерматовенеролога  П ¦
   ¦                                                              О ¦
   ¦ -----------------------------   ---------------------------- Т ¦
   ¦ ¦Дата¦Заключение¦Ф.И.О.,    ¦   ¦Дата¦Заключение¦Ф.И.О.,   ¦ Р ¦
   ¦ ¦    ¦  врача   ¦подпись и  ¦   ¦    ¦  врача   ¦подпись и ¦ Е ¦
   ¦ ¦    ¦          ¦личная пе- ¦   ¦    ¦          ¦личная пе-¦ Б ¦
   ¦ ¦    ¦          ¦чать врача ¦   ¦    ¦          ¦чать врача¦ Н ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ А ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ Д ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ З ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ О ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ Р ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ -----+----------+------------   -----+----------+-----------   ¦
   ¦                                                                ¦
   +-----                                                      -----+
   ¦ 22 ¦                                                      ¦ 23 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦ VIII. Результаты лабораторных         VIII. Результаты       О ¦
   ¦      исследований и осмотра      лабораторных исследований   С ¦
   ¦         дерматовенеролога       и осмотра дерматовенеролога  П ¦
   ¦                                                              О ¦
   ¦ -----------------------------   ---------------------------- Т ¦
   ¦ ¦Дата¦Заключение¦Ф.И.О.,    ¦   ¦Дата¦Заключение¦Ф.И.О.,   ¦ Р ¦
   ¦ ¦    ¦  врача   ¦подпись и  ¦   ¦    ¦  врача   ¦подпись и ¦ Е ¦
   ¦ ¦    ¦          ¦личная пе- ¦   ¦    ¦          ¦личная пе-¦ Б ¦
   ¦ ¦    ¦          ¦чать врача ¦   ¦    ¦          ¦чать врача¦ Н ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ А ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ Д ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ З ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ О ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ Р ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ -----+----------+------------   -----+----------+-----------   ¦
   ¦                                                                ¦
   +-----                                                      -----+
   ¦ 22 ¦                                                      ¦ 23 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦   IX. Результаты исследования    IX. Результаты исследования О ¦
   ¦          на гельминтозы                  на гельминтозы      С ¦
   ¦                                                              П ¦
   ¦ -----------------------------   ---------------------------- О ¦
   ¦ ¦Дата¦Заключение¦  Подпись, ¦   ¦Дата¦Заключение¦ Подпись, ¦ Т ¦
   ¦ ¦    ¦лаборато- ¦   печать  ¦   ¦    ¦лаборато- ¦  печать  ¦ Р ¦
   ¦ ¦    ¦рии       ¦  (штамп)  ¦   ¦    ¦рии       ¦ (штамп)  ¦ Е ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ Б ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ Н ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ А ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ Д ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ З ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ О ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ Р ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ -----+----------+------------   -----+----------+-----------   ¦
   ¦                                                                ¦
   +-----                                                      -----+
   ¦ 24 ¦                                                      ¦ 25 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦   X. Результаты исследования     XI. Результаты исследования О ¦
   ¦   на носительство возбудителей   на носительство патогенного С ¦
   ¦           дифтерии                       стафилококка        П ¦
   ¦                                                              О ¦
   ¦ -----------------------------   ---------------------------- Т ¦
   ¦ ¦Дата¦Заключение¦  Подпись, ¦   ¦Дата¦Заключение¦ Подпись, ¦ Р ¦
   ¦ ¦    ¦лаборато- ¦   печать  ¦   ¦    ¦лаборато- ¦  печать  ¦ Е ¦
   ¦ ¦    ¦рии       ¦  (штамп)  ¦   ¦    ¦рии       ¦ (штамп)  ¦ Б ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ Н ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ А ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ Д ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ З ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ О ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ Р ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ -----+----------+------------   -----+----------+-----------   ¦
   ¦                                                                ¦
   +-----                                                      -----+
   ¦ 26 ¦                                                      ¦ 27 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦     XII. Профессиональная        Отметка о предупреждении    О ¦
   ¦   гигиеническая подготовка и     при нарушении санитарных    С ¦
   ¦         аттестация                     норм и правил         П ¦
   ¦                                                              О ¦
   ¦ -----------------------------   ---------------------------- Т ¦
   ¦ ¦Дата¦Результаты¦Голограмма ¦   ¦Дата¦   Вид    ¦ Подпись  ¦ Р ¦
   ¦ ¦    ¦подготовки¦           ¦   ¦    ¦нарушения ¦          ¦ Е ¦
   ¦ ¦    ¦и аттеста-¦           ¦   ¦    ¦          ¦          ¦ Б ¦
   ¦ ¦    ¦ции       ¦           ¦   ¦    ¦          ¦          ¦ Н ¦
   ¦ +----+----------+-----------+   +----+----------+----------+ А ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦ Д ¦
   ¦ ¦    +----------+ Место под ¦   +----+----------+----------+ З ¦
   ¦ ¦    ¦          ¦квадратную ¦   ¦    ¦          ¦          ¦ О ¦
   ¦ ¦    +----------+голограмму ¦   +----+----------+----------+ Р ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ +----+----------+-----------+   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ ¦    +----------+           ¦   +----+----------+----------+   ¦
   ¦ ¦    ¦          ¦           ¦   ¦    ¦          ¦          ¦   ¦
   ¦ -----+----------+------------   -----+----------+-----------   ¦
   ¦                                                                ¦
   +-----                                                      -----+
   ¦ 28 ¦                                                      ¦ 29 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                              Р ¦
   ¦     Личная медицинская книжка                                О ¦
   ¦   утверждена         Приказом                                С ¦
   ¦   Федеральной службы       по                                П ¦
   ¦   надзору в сфере защиты прав                                О ¦
   ¦   потребителей и благополучия                                Т ¦
   ¦   человека от ________200_ г.                                Р ¦
   ¦   N _____, зарегистрированным                                Е ¦
   ¦   Минюстом         Российской                                Б ¦
   ¦   Федерации _________200_ г.,                                Н ¦
   ¦   регистрационный N ________.                                А ¦
   ¦     Личная медицинская книжка                                Д ¦
   ¦   приобретается             в                                З ¦
   ¦   организациях,                                              О ¦
   ¦   уполномоченных                                             Р ¦
   ¦   Роспотребнадзором.                                           ¦
   ¦     Личная медицинская книжка                                  ¦
   ¦   подлежит   голографированию                                  ¦
   ¦   в организациях,                                              ¦
   ¦   уполномоченных                                               ¦
   ¦   Роспотребнадзором                                            ¦
   ¦     Личная медицинская книжка                                  ¦
   ¦   должна    иметь      печать                                  ¦
   ¦   организации                                                  ¦
   ¦   Роспотребнадзора,  выдавшей                                  ¦
   ¦   медицинскую книжку, а также                                  ¦
   ¦   подпись владельца         и                                  ¦
   ¦   храниться  у  администрации                                  ¦
   ¦   организации             или                                  ¦
   ¦   индивидуального                                              ¦
   ¦   предпринимателя  и    может                                  ¦
   ¦   быть выдана работнику    по                                  ¦
   ¦   его требованию.                                              ¦
   ¦     При увольнении и переходе                                  ¦
   ¦   на другое место      работы                                  ¦
   ¦   личная медицинская   книжка                                  ¦
   ¦   остается у владельца      и                                  ¦
   ¦   предъявляется   по    месту                                  ¦
   ¦   новой работы.                                                ¦
   ¦     Профессиональная                                           ¦
   ¦   гигиеническая подготовка  и                                  ¦
   ¦   аттестация       проводятся                                  ¦
   ¦   только после     заключения                                  ¦
   ¦   врача о допуске к работе по                                  ¦
   ¦   результатам    медицинского                                  ¦
   ¦   обследования.     Результат                                  ¦
   ¦   аттестации               по                                  ¦
   ¦   профессиональной                                             ¦
   ¦   гигиенической    подготовке                                  ¦
   ¦   подтверждается      штампом                                  ¦
   ¦   организации, уполномоченной                                  ¦
   ¦   Роспотребнадзором.                                           ¦
   ¦     Личная медицинская книжка                                  ¦
   ¦   является документом строгой                                  ¦
   ¦   отчетности, защищенной   от                                  ¦
   ¦   подделок    полиграфической                                  ¦
   ¦   продукцией уровня "В"     и                                  ¦
   ¦   свободной     продаже    не                                  ¦
   ¦   подлежит.                                                    ¦
   ¦                                                                ¦
   +-----                                                      -----+
   ¦ 30 ¦                                                      ¦ 31 ¦
   -----+------------------------------------------------------+-----
   
   ------------------------------------------------------------------
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦                                                                ¦
   ¦      Изготовлено  в  Московской                                ¦
   ¦      типографии         Гознака                                ¦
   ¦      (лицензия  N  05-05-09/002                                ¦
   ¦      от 06.06.2003)                                            ¦
   ¦      @ Голографический  ламинат                                ¦
   ¦      ЗАО "Первый печатный двор"                                ¦
   ¦      (лицензия  N  05-05-09/017                                ¦
   ¦      от             11.08.2003)                                ¦
   ¦      Москва, 2005, "В".                                        ¦
   ¦                                                                ¦
   +-----                                                           ¦
   ¦    ¦                                                           ¦
   -----+------------------------------------------------------------
 
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