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Now ? / regular duty / Same employer 4. What is your gross pay (before taxes) per pay period? No, skip to Section F. / limited duty New employer Self employed How often are you paid? F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS 1. What w as the date of your first treatment? 2. Were you treated on site? Yes / None received (skip to question F-5) / No 3. Where did you receive your first off site medical treatment for your injury/illness? Doctor' s office Clinic/Hospital/Urge.

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