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Pca
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_SETUP.1
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INJRPT.BLD
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Wrap
Text File
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1997-07-22
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3KB
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101 lines
#100
@001 Enter the name of the EMPLOYEE:
~Enter the employee's full legal name.
@110 Enter the job title of the employee:
~Enter the title of the employee's position, such as
~file clerk, shift supervisor, etc.
@002 Enter the street address of the employee:
~Enter the mailing address of the employee's residence.
@003 Enter the city of the employee:
~Enter the city for the employee's mailing address.
@004 Enter the state where the employee resides:
~Enter the name of the state (or two digit code) where the
~employee resides.
@005 Enter the employee's zip code:
~Enter the zip code where the employee resides.
@101 Enter the social security number of the employee:
~Enter the employee's social security number.
#end control section
#100
ACCIDENT REPORT
Name of worker: @001 Social Security number: @101
Job title: @110
Address of worker: @002
City: @003 State: @004 Zip Code: @005
Date of injury: ______________________ Time of injury: _____________________
Place where injury took place: ___________________________________________
___________________________________________
How did the injury take place: ___________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Description of the injury: ______________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Part of body injured: ___________________________________________
ANY STATEMENTS MADE TO DEFRAUD THE EMPLOYER OR ANY INSURANCE CARRIER
ARE CRIMINAL VIOLATIONS.
______________________________________
@001
Report received by: ____________________________
Date: __________ Time: ___________