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Get NY CSEA DI 2012

_____ Mo. Day Year Date Last Worked: ______/_______/______ Mo. Day Year Have you attempted to return to your occupation since the date disability began? (If so, give details) ___________________________________________________________________________________________________________ If returned to work or recovered, give date: ____/_____/_____ Mo. Day Year Returned to work: Full Time: Part Time: If Part Time, # of hours per day _____ If not returned, when do you expect to? ___/____/______ Mo.

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