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Write down the essential details in First work day missed mm dd yyyy, Date injury was reported to the, Where did the injury occur County, If accident occurred outside of, Witnesses to the injury list by, Describe cause of injury or, Body parts affected by the injury, If injury is the result of an, III EMPLOYER INFORMATION at the, Employer address street citytown, Employer phone number, Supervisor name, IV DOCTOR INFORMATION Name of, Phone number, and Address street citytown state zip box.
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