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q 56.69 0 0 56.69 510.24 762.52 cm /I2 Do Q
BT /F1 12.00 Tf ET
BT 122.97 775.92 Td ( DICHIARAZIONE DI INFORTUNIO DA PARTE DEL DOCENTE) Tj ET
BT /F1 11.00 Tf ET
BT 31.19 743.63 Td (la presente dichiarazione NON esonera la scuola dalla trasmissione del Modulo Denuncia Sinistro) Tj ET
BT /F2 12.00 Tf ET
0.345 0.345 0.345 RG
0.992 0.886 0.506 rg
28.35 739.84 538.58 -14.17 re B q 0 g BT 229.96 729.15 Td (ISTITUTO SCOLASTICO) Tj ET Q
0.345 0.345 0.345 RG
BT /F3 9.00 Tf ET
28.35 725.67 99.21 -17.01 re S q 0 g BT 31.19 714.46 Td (Intestazione:) Tj ET Q
BT /F1 9.00 Tf ET
127.56 725.67 439.37 -17.01 re S q 0 g BT 130.40 714.46 Td (ISTITUTO COMPRENSIVO AZEGLIO) Tj ET Q
BT /F3 9.00 Tf ET
28.35 708.66 99.21 -17.01 re S q 0 g BT 31.19 697.45 Td (Indirizzo:) Tj ET Q
BT /F1 9.00 Tf ET
127.56 708.66 439.37 -17.01 re S q 0 g BT 130.40 697.45 Td (VIA XX SETTEMBRE 33 10010 AZEGLIO ) Tj ET Q
BT /F3 9.00 Tf ET
28.35 691.65 99.21 -17.01 re S q 0 g BT 31.19 680.45 Td (Telefono:) Tj ET Q
BT /F1 9.00 Tf ET
127.56 691.65 170.08 -17.01 re S q 0 g BT 130.40 680.45 Td (012572125) Tj ET Q
BT /F3 9.00 Tf ET
297.64 691.65 99.21 -17.01 re S q 0 g BT 300.48 680.45 Td (Fax:) Tj ET Q
BT /F1 9.00 Tf ET
396.85 691.65 170.08 -17.01 re S q 0 g BT 399.69 680.45 Td (0125687523) Tj ET Q
BT /F3 9.00 Tf ET
28.35 674.64 99.21 -17.01 re S q 0 g BT 31.19 663.44 Td (Cod. Ministeriale:) Tj ET Q
BT /F1 9.00 Tf ET
127.56 674.64 170.08 -17.01 re S q 0 g BT 130.40 663.44 Td (TOIC894006) Tj ET Q
BT /F3 9.00 Tf ET
297.64 674.64 99.21 -17.01 re S q 0 g BT 300.48 663.44 Td (Cod. Fiscale:) Tj ET Q
BT /F1 9.00 Tf ET
396.85 674.64 170.08 -17.01 re S q 0 g BT 399.69 663.44 Td (93041020012) Tj ET Q
BT /F3 9.00 Tf ET
28.35 657.63 99.21 -17.01 re S q 0 g BT 31.19 646.43 Td (E-mail:) Tj ET Q
BT /F1 9.00 Tf ET
127.56 657.63 439.37 -17.01 re S q 0 g BT 130.40 646.43 Td (icazeglio@segreteria.edu.it) Tj ET Q
BT /F3 9.00 Tf ET
28.35 640.63 283.46 -17.01 re S q 0 g BT 31.19 629.42 Td (N. Pol. infortuni/R.C./assistenza Chubb European Group SE:) Tj ET Q
BT /F1 9.00 Tf ET
311.81 640.63 255.12 -17.01 re S q 0 g BT 314.65 629.42 Td (ITBSTQ67187) Tj ET Q
BT /F3 9.00 Tf ET
28.35 623.62 70.87 -17.01 re S q 0 g BT 31.19 612.41 Td (Data effetto:) Tj ET Q
BT /F1 9.00 Tf ET
99.22 623.62 65.20 -17.01 re S q 0 g BT 102.05 612.41 Td (31/08/2021) Tj ET Q
BT /F3 9.00 Tf ET
164.41 623.62 79.37 -17.01 re S q 0 g BT 167.25 612.41 Td (Data scadenza:) Tj ET Q
BT /F1 9.00 Tf ET
243.78 623.62 65.20 -17.01 re S q 0 g BT 246.62 612.41 Td (31/08/2024) Tj ET Q
BT /F3 9.00 Tf ET
308.98 623.62 113.39 -17.01 re S q 0 g BT 311.81 612.41 Td (Periodo di assicurazione:) Tj ET Q
BT /F1 9.00 Tf ET
422.37 623.62 144.57 -17.01 re S q 0 g BT 425.20 612.41 Td (31/08/2021 - 31/08/2022) Tj ET Q
BT /F1 10.00 Tf ET
28.35 606.61 141.73 -17.01 re S q 0 g BT 31.19 595.11 Td (Data Sinistro:) Tj ET Q
170.08 606.61 113.39 -17.01 re S q 0 g BT 172.92 595.11 Td (Ora:) Tj ET Q
283.47 606.61 283.46 -17.01 re S q 0 g BT 286.30 595.11 Td (Luogo:) Tj ET Q
28.35 589.61 m 28.35 575.43 l S 28.35 589.61 m 226.77 589.61 l S 226.77 589.61 m 226.77 575.43 l S q 0 g BT 31.18 579.52 Td (Il sottoscritto ) Tj ET Q
28.35 575.43 m 28.35 561.26 l S 226.77 575.43 m 226.77 561.26 l S 28.35 561.26 m 226.77 561.26 l S q 0 g BT 31.18 565.35 Td (Cognome:) Tj ET Q
226.77 589.61 m 226.77 561.26 l S 226.77 589.61 m 425.20 589.61 l S 425.20 589.61 m 425.20 561.26 l S 226.77 561.26 m 425.20 561.26 l S q 0 g BT 229.61 572.43 Td (Nome:) Tj ET Q
425.20 589.61 m 425.20 561.26 l S 425.20 589.61 m 566.93 589.61 l S 566.93 589.61 m 566.93 561.26 l S 425.20 561.26 m 566.93 561.26 l S q 0 g BT 428.03 572.43 Td (Data di nascita:) Tj ET Q
28.35 561.26 m 28.35 547.09 l S 28.35 561.26 m 277.80 561.26 l S 277.80 561.26 m 277.80 547.09 l S q 0 g BT 31.19 551.17 Td (Al momento del fatto in servizio presso la scuola: ) Tj ET Q
28.35 547.09 m 28.35 532.91 l S 277.80 547.09 m 277.80 532.91 l S 28.35 532.91 m 277.80 532.91 l S q 0 g BT 31.19 537.00 Td ( ) Tj ET Q
BT /F3 8.50 Tf ET
q 0 g BT 31.18 538.87 Td (\(indicare l'indirizzo della sede/plesso dell'istituzione scolastica\)) Tj ET Q
277.80 561.26 289.13 -28.35 re S q 0 g BT 280.63 544.54 Td ( ) Tj ET Q
BT /F1 10.00 Tf ET
q 0 g BT 226.18 521.41 Td (COMUNICA CHE L'ALUNNO/A) Tj ET Q
28.35 515.91 269.29 -17.01 re S q 0 g BT 31.19 504.40 Td (Cognome:) Tj ET Q
297.64 515.91 269.29 -17.01 re S q 0 g BT 300.48 504.40 Td (Nome:) Tj ET Q
28.35 498.90 170.08 -17.01 re S q 0 g BT 31.19 487.39 Td (Nato a:) Tj ET Q
198.43 498.90 85.04 -17.01 re S q 0 g BT 201.26 487.39 Td (il:) Tj ET Q
283.47 498.90 283.46 -17.01 re S q 0 g BT 286.30 487.39 Td (Residente in Via:) Tj ET Q
28.35 481.89 85.04 -17.01 re S q 0 g BT 31.19 470.39 Td (CAP:) Tj ET Q
113.39 481.89 170.08 -17.01 re S q 0 g BT 116.22 470.39 Td (Citt:) Tj ET Q
283.47 481.89 127.56 -17.01 re S q 0 g BT 286.30 470.39 Td (Prov:) Tj ET Q
411.03 481.89 155.91 -17.01 re S q 0 g BT 413.86 470.39 Td (Classe/sezione:) Tj ET Q
q 0 g BT 229.03 450.54 Td (HA SUBITO UN INFORTUNIO) Tj ET Q
28.35 445.04 113.39 -17.01 re S q 0 g BT 31.19 433.54 Td (In data:) Tj ET Q
141.74 445.04 113.39 -17.01 re S q 0 g BT 144.57 433.54 Td (Alle ore:) Tj ET Q
q 0 g BT 236.54 413.69 Td (AL RIGUARDO DICHIARA) Tj ET Q
BT /F3 10.00 Tf ET
q 0 g BT 31.19 400.94 Td (- Che l'infortunio avvenuto nel seguente luogo:) Tj ET Q
28.35 396.85 m 28.35 354.33 l S 28.35 396.85 m 566.93 396.85 l S 566.93 396.85 m 566.93 354.33 l S 28.35 354.33 m 566.93 354.33 l S
q 0 g BT 31.19 341.41 Td (- Che al momento dell'infortunio era presente il seguente testimone:) Tj ET Q
BT /F1 10.00 Tf ET
28.35 337.32 269.29 -17.01 re S q 0 g BT 31.19 325.82 Td (Cognome:) Tj ET Q
297.64 337.32 269.29 -17.01 re S q 0 g BT 300.48 325.82 Td (Nome:) Tj ET Q
28.35 320.32 396.85 -28.35 re S q 0 g BT 31.19 303.14 Td (Indirizzo \(Via/Citt/Cap/Pr\):) Tj ET Q
425.20 320.32 141.73 -28.35 re S q 0 g BT 428.04 303.14 Td (Recapito Tel:) Tj ET Q
BT /F3 10.00 Tf ET
q 0 g BT 31.19 281.88 Td (- Che al momento dell'infortunio era presente il seguente testimone:) Tj ET Q
BT /F1 10.00 Tf ET
28.35 277.80 269.29 -17.01 re S q 0 g BT 31.19 266.29 Td (Cognome:) Tj ET Q
297.64 277.80 269.29 -17.01 re S q 0 g BT 300.48 266.29 Td (Nome:) Tj ET Q
28.35 260.79 396.85 -28.35 re S q 0 g BT 31.19 243.61 Td (Indirizzo \(Via/Citt/Cap/Pr\):) Tj ET Q
425.20 260.79 141.73 -28.35 re S q 0 g BT 428.04 243.61 Td (Recapito Tel:) Tj ET Q
BT /F3 10.00 Tf ET
q 0 g BT 31.19 222.35 Td (- Che l'infortunio avvenuto nel seguente modo \(descrizione particolareggiata dei fatti\)) Tj ET Q
28.35 218.27 538.58 -31.18 re S
q 0 g BT 31.19 177.00 Td (- Che l'infortunato stato immediatamente assistito dal/i Sig. \(Cognome/Nome/Via/Recapito Tel/Qualifica professionale\)) Tj ET Q
28.35 172.91 538.58 -31.18 re S
BT /F1 10.00 Tf ET
q 0 g BT 31.19 131.65 Td (Il sottoscritto dichiara che, pur essendo presente, si trovato nell'impossibilit di prevenire l'infortunio. ) Tj ET Q
q 0 g BT 31.19 117.47 Td (In fede) Tj ET Q
q 42.52 0 0 21.57 28.35 83.31 cm /I3 Do Q
q 42.52 0 0 22.18 297.64 82.70 cm /I4 Do Q
q 0 g BT 29.56 80.62 Td (________________________________________________) Tj ET Q
q 0 g BT 298.85 80.62 Td (________________________________________________) Tj ET Q
BT /F1 8.00 Tf ET
q 0 g BT 135.00 67.05 Td (\(Luogo e Data\)) Tj ET Q
q 0 g BT 388.66 67.05 Td (\(Firma dell'Insegnante\)) Tj ET Q
q 566.93 0 0 51.82 22.68 7.70 cm /I5 Do Q
q 85.04 0 0 16.20 481.89 31.99 cm /I6 Do Q
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