Professional Documents
Culture Documents
l{ithin
your initial examination, for every occupational injury or illness, send two copies of this rcport to the employer's workersr compensation
insurance carrier or the insured employer. Failure to file a timely doctorrs report may result in assessment of a civil penalty. In the case of diagnosed or
suspected pesticide poisoning, send a copy of the report to Division of Labor Statistics and Research, P.O. Box 420,603, San Francisco, CA 94142-0603, and
notify your local health officer bv telephone within 24 hours.
PI,EASE DO NOT
1' rNsuRER NAME AND ADD*tt
5 days of
Bo*"a \he
2.EMPLOYERNAME
3. Address
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4. Nature of business (e.g., food manufacturing, building construction, retailer of women's w'v',wr''
clothes.) 6-
Coutrty
5.
Bor.er
8. Address:
Occupation (Specificjob
10.
2. Injured at:
title)
\
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Mo.
of injury
or onset of illness
15. Date and hour
Yr
Day
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7. Date
VMul" ft Female
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6. Sex
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Age
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9. Telephone number
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Retum D.te/Code
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examination or treatment
not affect his/her rights to rvorkers' compensation under the Califomia Labor Code.
17. DESCRIBE HOW TIIE ACCIDENT OR EXPOSURE HAPPENED. (Give specific object, machinery or chemical. Use reverse side
required.)
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rr
SUBJECTM COMPLAINTS
18.
(Describe
fully.
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:/ es?ec\q\\\ o,Q\ec \onq t.rnV
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OBJECTM HNDINGS
19.
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20.DIAGNosIS(ifoccupationalillnessspecifyetiologicagentanddurationofexpoJure.;ct,"
ICD-9 Code
21.Areyourfindingsanddiagnosisconsistentwithpatient'sac"ountofi",priiieEplai,.
22. Is therc any other current condition that
23.
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25.
lt hosprtalized
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Doctor's
signrt
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DoctorName andDegree(ple"r"*yp"l
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