ACT No. 1 on an industrial accident

I APPROVE:

[signature] T. Ya. Gnatovskaya
(signature, f., i., o. of the employer)
09/29/99
(date)
L.S. [Place for Seal]

Form N-1

One copy is sent to the victim or their authorized representative

1. Date and time of the accident: September 16, 1999
   (day, month, year and ...)
   7 hours 57 minutes, on the way to work
   (time of the accident, number of full hours from the start of work)

2. Organization where the accident occurred: Okt. Highway, 33
   MU primary school - kindergarten No. 32 "Druzhnye Rebyata" [Friendly Kids]
   (name and address, industry)

3. Name of the workshop, section: —

4. Commission that conducted the investigation:
   * Lobova L. V. - deputy director for administrative and economic affairs - commission chairperson;
   * Mikheevicheva K. V. - chief accountant;
   * Danilova M. V. - after-school group teacher - trade union chairperson
   (f., i., o., position and place of work of the commission members)

5. Organization that sent the employee: —
   (name, address)

6. Information about the victim:
   * Surname, first name, patronymic: Dubinina Alla Viktorovna
   * Personnel No.: 1599
   * Gender: female
   * Age: 36 years
   * Profession, position: cook of the 4th category
   * Work experience in the job during which the accident occurred: 17 years 6 months
   (number of full years and months)

7. Conducting briefings and training on labor protection:
   * Introductory briefing: 03/01/93
   * Workplace briefing (initial, repeated, targeted) by profession or type of work during which the accident occurred: 09/06/99
   * Training in the profession or type of work during which the accident occurred: —
   * Knowledge check in the profession or type of work during which the accident occurred: —