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Get Action Paputok Injury Reduction Form

Ephone No.: Barangay: Sex: Middle Name: Municipality/City: Province: Age in: Years Months Days Male Female INCIDENT INFORMATION Date of Injury: Time of Injury: Date of Consultation: Time of Consultation: / / : : mm dd yyyy hh mm ss Address of Occurrence: House No. & Street: Type of Involvement: Active / / mm dd yyyy Barangay: Place of Occurrence: Home Street Other, specify: : : hh mm ss Municipal.

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