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Or Town) (State) (Zip) 7.Home Telephone 8.Date of Birth 9.Sex 10.Job Classification 11. Date of Hire 12.Date of Incident 13.Time of Incident 14.Time Employer Notified 16. Was Injury Fatal? YES NO 15.Date Employer Notified 17. Date of Fatality 18. How Did the Injury Occur? 19. Type of Injury 22. Did Injury Occur on Employer Premises? YES 21. Category of Illness or Injury 20. Body Part(s) Affected 23. Location Injury Occured NO 24. Injured Worker Seeking Medical Treatment YES i.

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