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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 duty New employer Same employer 4. What is your gross pay (before taxes) per pay period? No , skip to Section F. limited duty Self employed How often are you paid? F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS None received (.
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