Get WI WKC-12-E 2017-2021
Ry : Did Injury Cause Death? Yes No AM Number of Full-Time Employees Doing The Same Type Of Work: Last Day Worked Date Employer Notified : PM Date of Death Was This a Lost Time or Other Compensable Injury? No Was Employee Treated in an Emergency Room? Yes Name and Address of Treating Practitioner and Hospital: Case Number from the OSHA Log: Date Returned to Work Estimated Date of Return Did Injury Occur Because of: Substance Failure to Use Abuse Safety Devices Yes No No Was Employ.
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