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Get NY WCB C-3 2011

Es, notice was given to: ____________________________________ 11. Did anyone see your injury happen? Yes No orally No in writing Date notice given: _____/_____/_____ Unknown If yes, list names:________________________________________ E. RETURN TO WORK Yes, on what date? _____/_____/_____ 1. Did you stop work because of your injury/illness? 2. Have you returned to work? Yes No If yes, on what date? _____/_____/_____ 3. If you have returned to work, who are you working for now? regular.

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