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Get GA WC-R2 2011

SSN or Board Tracking # Date of Injury IDENTIFYING INFORMATION Catastrophic Injury? EMPLOYEE M.I. County of Injury Birthdate Yes No Diagnosis & Functional Restrictions Date last plans submitted / If expired, give reason New Plan Expectation Date SECTION 3 SECTION 2 REASON FOR REPORT ATTACHMENTS (You must attach all appropriate documents not previously submitted) As Directed by the Board Initial Rehabilitation Report Labor Market Survey 90-Day Report for Catastrophic Case Rehab.

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