Medical Conclusion on the Diagnosis of Health Damage

• Traumatic brain injury
• Concussion
• Lacerations on the occipital part and gluteal region
• Ruptured eardrum of the left ear

Persons Who Allowed the Violation of State Regulatory Requirements for Labor Protection

(Full name of persons with indication of the requirements they violated)

Organization Whose Employees These Persons Are

Witnesses of the Accident

• Seraya N. V., Okt. Shosse 35a - 42
  (Full name, their permanent place of residence, home telephone)
• Kovaleva L. V., Industrialnaya 9-51; tel. 3-11-96
• Kotovskaya T. Ya., Okt. Shosse 37-9, tel. 3-27-31

Measures and Deadlines for Eliminating the Causes of the Accident

TRUE COPY

Investigator [signature] Romanovsky V.V.

[Stamp: Investigation Service of the Directorate of the Federal Security Service of the Russian Federation for the Rostov Region * For inquiries 3]

Chairman of the commission: [signature] 16.09.99
Members of the commission: [signature] 16.09.99
[signature] 16.09.99