ࡱ> c 8sbjbj 7MbMb$$8 Q! %%%%"*Vx,T-PPPPPPP$SSV"Px.*""*x.x.P%%PWQ222x.F%%P2x.P22pJN %e㺹.MJPmQ0QMJuW0>uW NuW Npx.x.2x.x.x.x.x.PP2x.x.x.Qx.x.x.x.uWx.x.x.x.x.x.x.x.x.$B f: Insert self-insured employer and insurer name, address, phone number, and service company, if any.  FORMTEXT      Report of Job Injury or Illness Workers compensation claimWorker To make a claim for a work-related injury or illness, fill out the worker portion of this form and give it to your employer. If you do not intend to file a workers compensation claim with the insurance company, do not sign the signature line. Your employer will give you a copy.Date of injury or illness:  FORMTEXT      Date you left work:  FORMTEXT      Time you began work on day of injury:  FORMTEXT       FORMCHECKBOX  a.m.  FORMCHECKBOX  p.m.Regularly scheduled days off:  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  M T W T F S SDept Use: EmpTime of injury or illness:  FORMTEXT        FORMCHECKBOX  a.m.  FORMCHECKBOX  p.m.Time you left work:  FORMTEXT        FORMCHECKBOX  a.m.  FORMCHECKBOX  p.m.Check here if you have more than one job:  FORMCHECKBOX InsWhat is your illness or injury? What part of the body? Which side? (Example: Sprained right foot)  FORMCHECKBOX Left  FORMCHECKBOX Right  FORMTEXT      OccNatWhat caused it? What were you doing? Include vehicle, machinery, or tool used. (Example: Fell 10 feet when climbing an extension ladder carrying a 40-pound box of roofing materials)  FORMTEXT      PartEvSrc2srcInformation ABOVE this line; date of death, if death occurred; and Oregon OSHA case log number must be released to an authorized worker representative upon request. Your legal name:  FORMTEXT      Language preference:  FORMTEXT      Birthdate:  FORMTEXT      Gender: M  FORMCHECKBOX  F  FORMCHECKBOX Your mailing address:  FORMTEXT      Home phone:  FORMTEXT      Social Security no. (see Form 3283):  FORMTEXT      Occupation:  FORMTEXT      Work phone:  FORMTEXT       Names of witnesses:  FORMTEXT      Name and phone number of health insurance company:  FORMTEXT      Name and address of health care provider who treated you for the injury or illness you are now reporting:  FORMTEXT      Were you hospitalized overnight?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Were you treated in the emergency room?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoBy my signature, I am making a claim for workers compensation benefits. The above information is true to the best of my knowledge and belief. I authorize health care providers and other custodians of claim records to release relevant medical records to the workers compensation insurer, self-insured employer, claim administrator, and the Oregon Department of Consumer and Business Services. Notice: Relevant medical records include records of prior treatment for the same conditions or of injuries to the same area of the body. A HIPAA authorization is not required (45 CFR 164.512(I)). Release of HIV/AIDS records, certain drug and alcohol treatment records, and other records protected by state and federal law requires separate authorization. I understand I have a right to see a health care provider of my choice subject to certain restrictions under ORS 656.260 and ORS 656.325. Worker signature: Completed by (please print):  FORMTEXT . d f h v p ^ ͳߚ͑~xlaUaHB< h:CJ h}oCJh- h}oCJRH]aJh^h}o5CJaJh^h}oCJaJh&uh}o5CJ aJ h4CJh4h4CJaJh4CJaJh45CJ$aJ$1jh5CJOJQJU^JaJmHnHu2jh4h45CJOJQJU^JaJ#h4h45CJOJQJ^JaJ,jh4h45CJOJQJU^JaJh46CJaJ. f h v $Ifgd&u $$Ifa$gd5;Rkdv$$Ifl4!0Z*4 laf4yt- $$Ifa$gd4 $Ifgd4   X * h X~yyqyyy<$If$If<$If <$Ifgd9($If @ U  <$Ifgd9 @ U  ($If?kd$$Ifl4vZ**4 laf4yt&u    0 2 F H J T V X  𒰂o\$jh:5CJOJQJU$jPh:5CJOJQJUjh:5CJOJQJUh:5CJOJQJ$jh95CJOJQJU h:CJ h:5CJ)jh5CJOJQJUmHnHu$jDh95CJOJQJUh95CJOJQJjh95CJOJQJU   ( * d h j 026RTVX~ŹŪśŌ}n_Pjfh:5CJUjh:5CJUjh:5CJUjJh:5CJUjh:5CJUjh:5CJUj.h:5CJUjh:5CJU h:5CJ h:CJh:5CJOJQJjh:5CJOJQJU$jzh:5CJOJQJU~(*:<>Z\^`jl¯͚‡ta͚$jw h:5CJOJQJU$j h:5CJOJQJU$j h:5CJOJQJU)jh5CJOJQJUmHnHu$j h:5CJOJQJUh:5CJOJQJjh:5CJOJQJU h:5CJ h:5CJ h:CJ h:CJh:5;CJ!`QKKKKA $If^$If @ U  $Ifkd $$Ifl4ֈZ * j&*`R `~ `J`    4 laf4yt- <jL`QQQQKKK$If @ U  $Ifkda $$Ifl4ֈZ * j&* R  ~    J    ` 4 laf4yt-  <>@BLNjlnpz j|ؽqga؄a[U hEoCJ hWCJ h:CJh:B*CJph$jUh:5CJOJQJUh:5CJOJQJjh:5CJOJQJUhyhG1B*CJRH_phhyh:B*CJRH_phh:B*CJRH_phjh:5CJU h:CJj h:5CJU h:5CJjh:5CJU!Lz0kd$$Ifl4֞Z *j&*`(`*`G`7`@      4 laf4yt- $If^ $If^gd3$If  $If^$If @ U  $If FnvME?5 $If^$If$Ifkdj$$Ifl4֞Z *j&* ( * G 7 @    4 laf4yt-  68:FH\^`jlnvz:Fx xnhXRR hWCJjhCJUmHnHu h:CJh:CJOJQJ)jh5CJOJQJUmHnHu$j h:5CJOJQJUh:5CJOJQJjh:5CJOJQJUjh:CJUjh:CJUjh:5CJU h:5CJjh:5CJU h:CJ hCJ vxz&IA<$IfRkd7$$Ifl40Z&* %  4 laf4yt- $If^$IfRkd$$Ifl40Z&*`% 4 laf4yt-   &*04<@JL&¼¼¼¼®yn[yyRynh/h._CJ$jUh._5CJOJQJUh._5CJOJQJjh._5CJOJQJU h._CJ h:5hWh:5CJRH^hWhW56CJRH^hWh:56CJRH^ h:CJ h:CJ)jh5CJOJQJUmHnHujh:5CJOJQJU$jh:5CJOJQJU&(*024<IRkd$$Ifl40Z&* %  4 laf4yt- $If^$IfRkdN$$Ifl40Z&*`% 4 laf4yt- <>@JLE/ *e($If^`eRkd1$$Ifl40Z&* %  4 laf4yt $If^ (($IfRkd$$Ifl40Z&* %  4 laf4yt- 8vtd$If^gdGd$If^gde:d$If]gde:d$If]gdGOkd$$Ifl4Z**   4 laf4p yt&(*46NPdfhrtǷͷNJnNJ\UPJ hdDCJ h._5 h._5CJ"j=h h 5CJU"jh h 5CJUh h._5CJjh h._5CJU$jAh95CJOJQJUh95CJOJQJjh95CJOJQJU h._CJjhe:5CJOJQJUjh._5CJOJQJU$jh._5CJOJQJU,l}n_3d$If^3gdGd$If^gdGkd$$Ifl4/\Z<%* #2 H2 +4 laf4yte:(*,DFZ\^hjln𳐃v_L$hBkhdD5B*CJOJQJph-jhBkhdD5B*CJOJQJUphhBkhdDB*CJphh/hdDB*CJphhdD5B*ph$jhdD5CJOJQJU hdDCJhdDB*CJph)jh5CJOJQJUmHnHu$johdD5CJOJQJUhdD5CJOJQJjhdD5CJOJQJUln b7d$If^7gdGd$If^gdGd$If]gdGRkd[$$Ifl40Z* 4 laf4yt- 8:NPR\^bdδΪvaNaDhdD5B*ph$jhdD5CJOJQJU)jh5CJOJQJUmHnHu$j_hdD5CJOJQJUhdD5CJOJQJjhdD5CJOJQJU hdDCJ *h7}vhdDCJ2jh5B*CJOJQJUmHnHphu-jhBkhdD5B*CJOJQJUph3jhBkhdD5B*CJOJQJUphbdDNDD<$If $If^?kd] $$Ifl4Z**4 laf4yt- d$IfgdGekdK$$Ifl4:FZ6*      4 laf4yt- dȮ۔vi\R;-jhBkhEo5B*CJOJQJUphhEoB*CJphh/hB*CJphh/h+aB*CJphh3B*CJphh+aB*CJphh:5B*ph2jh5B*CJOJQJUmHnHphu3jhBkh:5B*CJOJQJUph$hBkh:5B*CJOJQJph-jhBkh:5B*CJOJQJUphhBkh:B*CJph246@BDFd.02<>@ӼkX>kk0hBkh:5CJOJQJ3j7!hBkh:5B*CJOJQJUph$hBkh:5B*CJOJQJph-jhBkh:5B*CJOJQJUphhBkh:B*CJphh+aB*CJphhBkh:CJ2jh5B*CJOJQJUmHnHphu-jhBkhEo5B*CJOJQJUph3j hBkhEo5B*CJOJQJUph$hBkhEo5B*CJOJQJph@BB6  ($IfRkdH#$$Ifl40Z*   4 laf4yt-   ($Ifgd-Rkd!$$Ifl40Z*` 4 laf4yt- $If@LNjlnpz|abulch&aCJRH_hhG1CJRH_hh/hG1CJRH_hh:CJRH_hh:5CJhj{$h:5CJUj$h:5CJUh:B*phh:B*CJphj"h:5CJUj\"h:5CJU h:5CJjh:5CJU h-CJ h:CJ#LMNz:?kd%$$Ifl48Z*`*4 laf4yt- $Ifgdy$$If^a$gd- ($If^gdG1Rkd$$$Ifl40Z*   4 laf4yt- $If^e(JKLMNV̸̯viUOIB h:CJh h:CJ h~NCJ'h\*h:5B*CJRH_aJhphh5CJRH_aJhhh 5CJRH_aJhhh\*5CJRH_aJhhhy5CJRH_aJhhyCJRH_hhBkCJRH_hhbCJRH_hh:5CJRH_hh:CJRH_hhBkh'bCJRH_hhBkhvCJRH_hhCJRH_hhvCJRH_hNOPQRSTy9?kd&$$Ifl48Z* * 4 laf4yt- ?kdr&$$Ifl48Z* * 4 laf4yt- ?kd%$$Ifl48Z* * 4 laf4yt- $IfTUV]jxbbDbxrg $Ifgd9$If $If] $If] $If]gdG $If]?kd`'$$Ifl4Z* * 4 laf4yt- $IfV b b bbbb2b4b6b@bBbDbƱ榘t]C3h:5B*CJOJQJph2jh5B*CJOJQJUmHnHphu-jM(h95B*CJOJQJUphh95B*CJOJQJph'jh95B*CJOJQJUphh:B*CJOJQJphh:5CJOJQJ)jh5CJOJQJUmHnHuU$j'h:5CJOJQJUh:5CJOJQJjh:5CJOJQJUh:CJOJQJ      Date:  FORMTEXT      Employer Complete the rest of this form and give a copy of the form to the worker. Even if the worker does not want to file a claim, keep a copy of this form.Employer legal business name:  FORMTEXT      Phone:  FORMTEXT      FEIN:  FORMTEXT      If worker leasing company, list client business name:  FORMTEXT      Client FEIN:  FORMTEXT      Address of principal place of business (not P.O. Box):  FORMTEXT      Insurance policy no.:  FORMTEXT      Street address from which worker is/was supervised:  FORMTEXT      ZIP:  FORMTEXT      Nature of business in which worker is/was supervised:  FORMTEXT      Address where event occurred:  FORMTEXT      Was injury caused by failure of a machine or product, or by a person other than the injured worker?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoWere other workers injured?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoOSHA 300 log case no:  FORMTEXT      Date employer knew of claim:  FORMTEXT      Date worker returned to work:  FORMTEXT      Worker s weekly wage: $ FORMTEXT      Date worker hired:  FORMTEXT      If fatal, date of death:  FORMTEXT      By my signature, I acknowledge I am responsible for notifying my workers compensation insurance company within five days of knowledge of the claim. I understand I may not restrict the worker s choice of or access to a health care provider. If I do, it could result in civil penalties under ORS 656.260.Employer signature:Name and title (please print):  FORMTEXT      Date:  FORMTEXT      440-801(1/17/DCBS/WCD/WEB)OSHA requirements: Employers must report work-related fatalities and catastrophes to Oregon OSHA either in person or by telephone within eight hours. In addition, employers must report any in-patient hospitalization, loss of an eye, and any amputation or avulsion that results in bone or cartilage loss to Oregon OSHA within 24 hours. See OAR 437-001-0704. Call 800-922-2689 (toll-free), 503-378-3272, or Oregon Emergency Response, 800-452-0311 (toll-free), on nights and weekends.801     DbFbHbJbLbNb-ekd~)$$Ifl4FZ:D%*           4 laf4yt- $Ifekd($$Ifl4FZ:D%*`` `    4 laf4yt- DbFbVbhbbbb6cd@dTdVdXdbdddfdhddddddddee.e0e2eezeeeeeeeeef ff f"fߞߋr_$j/h:5CJOJQJU$jL/h:5CJOJQJU hWCJ$j.h:5CJOJQJU$j-h:5CJOJQJU h:CJ)jh5CJOJQJUmHnHu$j8,h:5CJOJQJUh:5CJOJQJjh:5CJOJQJU h:CJ%fdhddd e@er_QC9 $If]($If]$If]^($If]^gdGkd,$$Ifl4FZ* @ 0    4 laf4yt- @eBezeee0fubRD$If]^<$If]^($If]^gdFw($If]^ykd}.$$Ifl40Z*J@ 04 laf4yt- "f,f.fffffffffffffffffdgfgzg|g~ggggggggggggɶԭɚɇɀvivYvjhCJUmHnHuj,3h:CJUjh:CJU h:5CJ$j1h:5CJOJQJU$j}1h:5CJOJQJUh>h:CJ$j1h:5CJOJQJUh:5CJOJQJ h:CJjh:5CJOJQJU)jh5CJOJQJUmHnHu"0f2fhfffdgg}ww}}$If<$Ifykd80$$Ifl40Z*J@ 04 laf4yt- ggggggi5Rkd3$$Ifl40Z*J @ 4 laf4yt- $If ($IfgdGekdi2$$Ifl4FZ^*F`@     4 laf4yt- gggghhhhhhhhhiiiiiViXitivixiziiiiiiiiiiiiƳƠƍzpj hWCJh:CJOJQJ$j6h:5CJOJQJU$j5h:5CJOJQJU$j4h:5CJOJQJU$j54h:5CJOJQJUh:5CJOJQJjh:5CJOJQJUh:B*CJph h:5CJ h:CJ h:5CJ"iiijj"jhjjjjd[[ $Ifgd9Rkd6$$Ifl4 0Z *4 laf4yt- <$If?kd!5$$Ifl41Z**4 laf4yt- iiiijjj@jBjVjXjZjdjfjjjjjjjjjkkkk"k$k&k»«ȫ«zȫpcpSpHh:5CJOJQJjhCJUmHnHuj8h:CJUjh:CJU$j8h95CJOJQJU$j7h95CJOJQJUh95CJOJQJjh95CJOJQJU h:5CJ h:CJ)jh5CJOJQJUmHnHujh:5CJOJQJU$jw6h:5CJOJQJUj&k@kvkkkk4n\Q <$IfgdJ:kd:$$Ifl4rZ  #*~ $ $ bb4 laf4yt- $Ifgd9<$If$If&kNkPkdkfkhkrktkvkkkkkkkkkkkllmmmmmm2nߝ갖|n`RnRn`hhGE5CJRH]aJhh1i5CJRH]aJhhJ:5CJRH]aJhhJ:CJRH]aJhh1iCJRH]aJ h:5CJ$j9h95CJOJQJU h:5CJ)jh5CJOJQJUmHnHu$j9h95CJOJQJUh95CJOJQJjh95CJOJQJU h:CJ2n4n6n^n`nnnnnnnnnnnnnnnnnnnoooǴҟ鏄qmcYLh%phmoCJRHZaJhv2CJRH_aJh%pCJRH_aJh:$j;h95CJOJQJUh95CJOJQJjh95CJOJQJU)jh5CJOJQJUmHnHu$j+;h:5CJOJQJUh:5CJOJQJjh:5CJOJQJU h:5CJ h:CJh1ihv2h1iCJRH]aJ4n6nJn`nnnn <$Ifgd9($If^`($If^`($If]^?kd:$$Ifl4Z**4 laf4yt- nn4ors{ $$Ifa$gd%p $Ifgd- $Ifgdekd'<$$Ifl4FZ#*b    4 laf4yt- oo2o4oXorrrssss s sssssss s"s$s&s(s*s,s.s0s2s4s6s8s̾hfhv2ht=jht=U h:CJ h%p5CJh- h- 5CJ8aJ8 h- h- hJ:CJRH^aJhh- h- CJRH^aJhh- h- 5CJRH^aJhh%ph- CJRH_aJh%phmoCJRHZaJhCJRHZaJ ssss ssssssss s"s$s&s(s*sekd<$$Ifl4FZU&*`/    4 laf4ytv2*s,s.s0s2s4s6s8s5 0&P:pu/ =!@"@#@$% vDText81v$$If!vh#v#v:V l4!,55/ 4af4yt- T$$If!vh#v*:V l4v5*4af4yt&uDText41M/d/yyyyDText42M/d/yyyyvDText77DeCheck21Check if start shift is in A.M.DeCheck22Check if start shift is in P.M.DeCheck22Check if start shift is in P.M.DeCheck22Check if start shift is in P.M.DeCheck22Check if start shift is in P.M.DeCheck22Check if start shift is in P.M.DeCheck22Check if start shift is in P.M.DeCheck22Check if start shift is in P.M.DeCheck22Check if start shift is in P.M.E$$If!vh#vR #v~ #v#vJ#v#v:V l4+++++,5R 5~ 55J55/ /  / /  / / / /  /  / 4af4yt- 6$$If!vh#vR #v~ #v#vJ#v#v:V l4++++++5R 5~ 55J55/ /  / / /  /  /  / / 4af4yt- vDText75DeCheck21Check if start shift is in A.M.DeCheck22Check if start shift is in P.M.vDText76DeCheck21Check if start shift is in A.M.DeCheck22Check if start shift is in P.M.vDeCheck42$$If!vh#v(#v*#vG#v7#v@ #v#v:V l4+++++++5(5*5G575@ 55/ / / /  / /  / / / / /  / /  / / 4af4yt- $$If!vh#v(#v*#vG#v7#v@ #v#v:V l4++++++5(5*5G575@ 55/ / / /  / /  / / / / /  / / / 4af4yt- DeCheck21Check if start shift is in A.M.vDeCheck43vDText44$$If!vh#v%#v:V l4+5%5/ /  / / 4af4yt- $$If!vh#v%#v:V l4+5%5/  / / / 4af4yt- vDText45$$If!vh#v%#v:V l4+5%5/ /  / / 4af4yt- $$If!vh#v%#v:V l4+5%5/  / / / 4af4yt- $$If!vh#v%#v:V l4+5%5/  / / / 4af4yt- $$If!vh#v%#v:V l4+5%5/  / / / 4af4yt$$If!vh#v*:V l4   5*/ 4af4p ytvDText46vDText52DText47M/d/yyyyvDCheck41vDCheck42$$If!vh#v#v #v##v:V l4/55 5#5/  /  / 2 H2 +4af4yte:vDText48vDText49$$If!vh#v#v :V l455 / /  / 4af4yt- vDText50vDText52vDText51$$If!vh#v#v #v :V l4:55 5 /  /  / 4af4yt- vDText53b$$If!vh#v*:V l45*/ 4af4yt- vDText54vDText55$$If!vh#v#v :V l4+55 / / / /  / 4af4yt- vDeCheck41vDeCheck42$$If!vh#v#v :V l4+55 / / / /  / /  4af4yt- vDeCheck41vDeCheck42$$If!vh#v#v :V l4+55 /  /  / / 4af4yt- g$$If!vh#v*:V l48+5*/  4af4yt- u$$If!vh#v*:V l48+5*/  /  4af4yt- u$$If!vh#v*:V l48+5*/  /  4af4yt- u$$If!vh#v*:V l48+5*/  /  4af4yt- u$$If!vh#v*:V l4+5*/  /  4af4yt- vDText34DText56M/d/yyyy$$If!vh#v#v #v:V l4+++55 5/ /  / 4af4yt- $$If!vh#v#v #v:V l4+++55 5/ /  / /  4af4yt- $$If!vh#v#v #v:V l4+++55 5/ /  / /  4af4yt- Z$$If!vh#v*:V l4,5*4af4yt&uvDText78vDText57vDText58$$If!vh#v#v #v@ :V l40,55 5@ /  /  / / 4af4yt- vDText66vDText59$$If!vh#vJ#v@ :V l405J5@ /  /  / / 4af4yt- vDText61vDText60$$If!vh#vJ#v@ :V l405J5@ /  / / / 4af4yt- vDText79vDText80vDText64$$If!vh#v#vF#v@ :V l4+,55F5@ / / /  / / 4af4yt- vDText65$$If!vh#vJ#v@ :V l4+5J5@ /  / / 4af4yt- vDeCheck41vDeCheck42h$$If!vh#v*:V l41,5*/ 4af4yt- vDeCheck41vDeCheck42vDText67$$If!vh#v#v:V l4 ,55/ / / / 4af4yt- DText68M/d/yyyyDText69M/d/yyyyvDText70DText71M/d/yyyyDText72M/d/yyyy$$If!vh#v~ #v$ #vb:V l45~ 5$ 5b/ /  /  / 4af4yt- b$$If!vh#v*:V l45*/ 4af4yt- vDText73DText74M/d/yyyy$$If!vh#v#v#vb:V l4,555b/ / / / 4af4yt- $$If!vh#v#v`#v/:V l4,55`5// 4af4ytv2,s666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH <`< NormalCJ_HmH sH tH HH  Heading 1$<@& 5CJKH@@  Heading 2$<@&5<<  Heading 3$<@&PP  Heading 4$$@&a$CJ OJQJhtH uzz  Heading 54$$ =d,:@&^`=a$5CJOJQJhtH ull  Heading 6*$ ]d+@&^`]5OJQJhtH unn  Heading 7*$ ]d+@&^`]5B*OJQJhtH u<<  Heading 8$@&5CJD D  Heading 9 $@&^5CJDA D Default Paragraph FontVi@V 0 Table Normal :V 44 la (k ( 0No List :1:  List Number  & F >:>  List Number 2  & F >;>  List Number 3  & F ><">  List Number 4  & F >=2>  List Number 5  & F DBD Quote Indent]^4@R4 Header  !4 @b4 +0Footer  !DB@rD  Body TextCJOJQJhtH u>6>  List Bullet 2  & F pCp Body Text Indent$ ]d+^`]OJQJhtH u@P@  Body Text 2$a$5CJBQB  Body Text 3 V]V5CJNN Subhead 1 dCJOJQJhtH uv/v Hanging indent  d^`CJOJQJ_HhmH sH tH `/` Body text dH(B*CJOJQJ_HhmH phsH tH fRf Body Text Indent 2$ [d^`[CJXSX Body Text Indent 3 <^CJ0U 0  Hyperlink>*B*@V !@ FollowedHyperlink>*B* B' 1B S"0Comment ReferenceCJaJ8B8 %S"0 Comment Text$CJ:Q: $S"0Comment Text Char@jAB@ 'S"0Comment Subject&5\F/qF &S"0Comment Subject Char5\HH )S"0 Balloon Text(CJOJQJ^JaJN/N (S"0Balloon Text CharCJOJQJ^JaJ@ @._0Revision*CJ_HmH sH tH 2/2 &SR0 Footer CharCJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w<v 2   ~ &d@VDb0d"fgi&k2no8s"$&()+-0;>ADFHIL L v&<lbNTDbNbcfd@e0fgij4nns*s8s !#%'*,./:<=?@BCEGJKMNcou$*S_egw~ *&6gw #/5 '39EUYi(.FRX   D T [ k  ".4o{ HTZ{AQXh!'=IOkw} 2F4F4F4FG$G$G$G$G$G$G$G$G$FG$G$FG$G$G$G$G$F4F4F4F4F4G$G$F4F4F4F4F4F4F4FG$G$G$G$FF4FtFFFFFFFTFTFFG$G$G$G$FF4F4FF4F4FF4  p0e0e     o 8c8c     ?1 d0u0@Ty2 NP'p<'pA)BCD|E||@H 0(  6(  t  6?"?B S  ? B2*t*Text81Text41Text42Text77Text75Text76Check43Text44Text45Text46Text47Text48Text49Text50Text52Text51Text53Text54Text55Text34Text56Text78Text57Text58Text66Text59Text61Text60Text63Text79Text80Text64Text65Text67Text68Text69Text70Text71Text72Text73Text74_GoBackdT $'G #pI|=k3  !"#$%&'()v+f6 :/Y 5[(P~3 !#$03cv+Sf#6 /FY  "5oH[{(=Pk~3cv+Sf#6 ''::;;TUhi/FY  a b "5oH[{(=Pk~$03"|H6}E*Q~\L;ZfJ=6K9  3ze* 0`U;-':dO0X Wi ?3!w;u( / N8#1 v8 Pu:bsz$HE@?{pI 1M ]*OFeRP*n&Q QzP!R GS xjU /=[(mo oD7^-2bpʶ"@Jr ^`.^`.88^8`.^`. ^`OJQJo(hh^h`.hh^h`o(.0^`0o(-0^`0o(-.0^`0o(-..88^8`o(-... 88^8`o( -.... `^``o( -..... ^`o(-...... ^`o(-....... pp^p`o(-........ hh^h`56B*o(.->^`>o(.>^`>o(. hh^h`o(. hh^h`OJQJo(0^`0o(-0^`0o(-.0^`0o(-..88^8`o(-... 88^8`o( -.... `^``o( -..... ^`o(-...... ^`o(-....... pp^p`o(-........hh^h`o(. hh^h`OJQJo( hh^h`5B*o(.hh^h`o(.hh^h`56CJOJQJo(.^`56CJOJQJo(.88^8`56CJOJQJo(()^`()p^`p()pp^p`()  ^ `.@ @ ^@ `.  ^ `. hh^h`B*OJQJo(.hh^h`) hh^h`o(.hh^h`56CJOJQJo(.^`56CJOJQJo(.88^8`56CJOJQJo(()^`()^`()pp^p`()  ^ `.@ @ ^@ `.  ^ `. hh^h`56B*o(.hh^h`o(.hh^h`o(. hh^h`OJQJo( hh^h`OJQJo(hh^h`o(.0^`0o(-0^`0o(-.0^`0o(-..88^8`o(-... 88^8`o( -.... `^``o( -..... `^``o(-...... ^`o(-....... ^`o(-........hh^h`o(.^`o(. hh^h`B*OJQJo(. hh^h`OJQJo('Pu:Pu:~Pu:}Pu:|Pu:Pu:]*O/JrWiP!R{pIGSo/=[`U': 3?3!N8#1RPz$HE-2bpe* 0XQ1M9moxjUn&Qv8;u("" NH&a+aK 7; /N g >&un<Eom{n9G9}o :7S"m"Y$H%-& 'd)\*e*qv+(01G1.b1s1I12v23H9:e:5;!<3@`8@U@|BBdDvoDIE.LfN~NOLPqPQ8R&SRSRbzR1X _U_)`@a'bjg1ik lSfm%n/hnmo%p4rEr7}vFwJ:wt D)u QD2mWBkGE?vx- yRg19;1.>*lfy/G9g/~E6t=6vb82v:e-+._''[Og ^14l#Y@ pupp 2 8@bUnknownG.[x Times New Roman5Symbol3. .Cx ArialI B Helvetica BoldS  PalatinoBook Antiqua3.[x Times5. .[`)TahomaA$BCambria Math"h2Q|'2Q L (L (a0  2QHP $P7*!xxpAH Report of Job Injury or IllnessReport of Job Injury or Illness FROI First Report Injury DiseaseShelly CochranShelly L Cochran"                           ! Oh+'0,D `l     Report of Job Injury or Illness Report of Job Injury or IllnessShelly Cochran$FROI First Report Injury Disease7F52B91B.dotmShelly L Cochran13Microsoft Office Word@_@c9h@c9h@˺L ?@ABCDEFGHIJKLMNOQRSTUVWXYZ[\]^_`abcdefghijklmnpqrstuvwxyz{|}~Root Entry FлData P]=1Tableo XWordDocument7SummaryInformation(DocumentSummaryInformation8!MsoDataStore ллQOR5SUA0EFFFRUA==2ллItem  PropertiesOLIURUHHNYN==2 ллItem  Properties SJYVJGXBPFRQ==2ллItem PropertiesUROURZCOS40K==2ллItem O0PropertiesCompObj.r  "#$%&'()*+,-0/123456789:DocumentLibraryFormDocumentLibraryFormDocumentLibraryForm emID="{495FE440-8049-4F68-85E3-D145DFD47E50}" xml This value indicates the number of saves or revisions. The application is responsible for updating this value after each revision. For use by injured workers and employers in reporting injury or illness claims800801.0000000000008011012017-01-01T00:00:00Z;#First report of injury;#K0x0101009746DEC5A34E424E9259CD3C9ED8D0A5003E4DBADB74648947A577E03CDAF44324801ccurs="0" maxOccurs="1" type="xsd:string"/> This value indicates the number of saves or revisions. The app> lns:pc="http://schemas.microsoft.com/office/infopath/2007/PartnerControls" xmlns:xs="http://www.w3.org/2001/XMLSchema"> osoft.com/office/2006/metadata/longProperties"/>="{9588BCA8-BB4E-4C45-87AC-7F8D634376DA}" xml"1.0" encoding="UTF-8" standalone="no"?> {5458E2F3-C69B-4F5E-813F-EF6C151EAE42}" xml tastoreItem>s>