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Get GA WC-R2 2018-2024

N M.I. IDENTIFYING INFORMATION Catastrophic Injury? 0 0 Diagnosis & Functional Restrictions Yes No County of Injury Date of Injury Birthdate 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) 0 As Directed by the Board 0 Initial Rehabilitation Report 0 Labor Market Survey 0 90-Day Report for Catastrophic Case 0 Rehabilitation Pro.

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