| 1 | OOPSP50 ;HINES CIOFO/YH-REPORT OF ACCIDENT CA2 - PAGE 2 ;2/21/98
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| 2 | ;;2.0;ASISTS;;Jun 03, 2002
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| 3 | ;;
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| 4 | EN1 ;RESET PRINTRA, SET PAGE SIZE (PORTRAIT) AND PCL PICTURE FRAME 8 1/2"*11"
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| 5 | W !,$CHAR(27),"E",$CHAR(27),"&l1E",$CHAR(27),"*c5952x7920Y",$CHAR(27),"%0B",$CHAR(27),"&s1#C"
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| 6 | W !,"IN;SP1;IP;PW.3;SC0,22,0,29,1;"
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| 7 | W !,"DT@,1;SD1,277,2,1,4,9,5,0,6,1,7,23;"
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| 8 | W !,"PU.5,28.8;LBOfficial Supervisor's Report of Occupational Disease: Please complete information requested below@;"
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| 9 | W !,"PU.4,28.2;FT10,10;RA21,28.6;PU.5,28.6;PD21,28.6;PU.5,28.3;LBSupervisor's Report@;PU.5,28.2;PD21,28.2;"
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| 10 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 11 | W !,"PU.5,27.9;LB19. Agency name, and address of reporting office (Include city, state, and zip code)@;"
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| 12 | W !,"PU16.2,28.2;PD16.2,27.3;PU16.3,27.9;LBOWCP Agency Code@;"
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| 13 | W !,"PU15.2,26.4;PD15.2,27.3;PU15.3,27;LBOSHA Site Code@;PU12,26.1;LBZip Code@;PU17.5,25.3;LBZip Code@;"
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| 14 | W !,"PU.5,27.3;PD21,27.3;PU.5,26.4;PD21,26.4;"
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| 15 | W !,"PU.5,25.6;PD21,25.6;"
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| 16 | W !,"PU.5,25.3;LB20. Employee's duty station (Street address and zip code)@;"
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| 17 | W !,"PU.5,24.7;PD21,24.7;"
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| 18 | W !,"PU.5,24.4;LB21. Regular@;PU1.1,24.1;LBwork@;PU1.1,23.8;LBhours@;PU2.2,23.8;LBFrom@;SD1,277,2,1,4,9,5,0,6,5,7,23;PU3.4,23.8;LB:@;"
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| 19 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 20 | W !,"PU4.1,24.2;EA4.3,24.4;PU4.5,24.2;LBa.m.@;PU4.1,23.8;EA4.3,24;PU4.5,23.8;LBp.m.@;PU5.8,23.8;LBTo@;"
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| 21 | W !,"SD1,277,2,1,4,9,5,0,6,5,7,23;PU6.8,23.8;LB:@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 22 | W !,"PU7.4,24.2;EA7.6,24.4;PU7.8,24.2;LBa.m.@;PU7.4,23.8;EA7.6,24;PU7.8,23.8;LBp.m.@;"
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| 23 | W !,"PU8.9,24.7;PD8.9,23.4;PU9,24.4;LB22. Regular@;PU9.6,24.1;LBwork@;PU9.6,23.8;LBschedule@;"
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| 24 | W !,"PU11,23.8;EA11.2,24;PU11.4,23.8;LBSun.@;PU12.3,23.8;EA12.5,24;PU12.7,23.8;LBMon.@;"
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| 25 | W !,"PU13.6,23.8;EA13.8,24;PU14,23.8;LBTues.@;PU14.9,23.8;EA15.1,24;PU15.3,23.8;LBWed.@;"
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| 26 | W !,"PU16.2,23.8;EA16.4,24;PU16.6,23.8;LBThurs.@;PU17.7,23.8;EA17.9,24;PU18.1,23.8;LBFri.@;"
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| 27 | W !,"PU18.8,23.8;EA19,24;PU19.2,23.8;LBSat.@;"
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| 28 | W !,"PU.5,23.5;PD21,23.5;PU.5,23.2;LB23. Name and address of physician first providing medical care@;"
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| 29 | W !,"LB (Include city, state, zip code)@;"
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| 30 | W !,"PU13.9,23.5;PD13.9,21;PU14,23.2;LB24. First date@;PU17.5,23.2;LBMo.@;PU18.4,23.2;LBDay@;PU19.3,23.2;LBYr.@;"
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| 31 | W !,"PU14.5,22.9;LBmedical@;PU14.5,22.6;LBcare received@;PU13.9,22.3;PD21,22.3;"
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| 32 | W !,"PU17.3,22.4;PD19.9,22.4;PU17.3,22.4;PD17.3,22.6;PU18.2,22.4;PD18.2,22.6;PU19.1,22.4;PD19.1,22.6;PU19.9,22.4;PD19.9,22.6;"
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| 33 | W !,"PU14,22;LB25. Do medical reports@;PU14.5,21.7;LBshow employee is@;PU14.5,21.4;LBdisabled for work?@;"
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| 34 | W !,"PU17.5,21.7;EA17.7,21.9;PU17.9,21.7;LBYes@;PU18.9,21.7;EA19.1,21.9;PU19.3,21.7;LBNo@;"
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| 35 | W !,"PU.5,22.6;PD13.9,22.6;PU.5,21.8;PD13.9,21.8;PU.5,21;PD21,21;"
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| 36 | W !,"PU.5,20.7;LB26. Date employee@;PU3.4,20.7;LBMo.@;PU4.3,20.7;LBDay@;PU5.3,20.7;LBYr.@;"
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| 37 | W !,"PU6.2,20.7;PD6.2,19.7;PU6.3,20.7;LB27. Date and@;PU9.4,20.7;LBMo.@;PU10.2,20.7;LBDay@;PU11.2,20.7;LBYr.@;"
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| 38 | W !,"PU1.1,20.4;LBfirst reported@;PU1.1,20.1;LBcondition to@;PU1.1,19.8;LBsupervisor@;"
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| 39 | W !,"PU3.2,20.1;PD5.9,20.1;PU3.2,20.1;PD3.2,20.3;PU4.1,20.1;PD4.1,20.3;PU5,20.1;PD5,20.3;PU5.9,20.1;PD5.9,20.3;PU6.2,21;PD6.2,19.7;"
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| 40 | W !,"PU6.9,20.4;LBhour employee@;PU6.9,20.1;LBstopped work@;"
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| 41 | W !,"PU9.2,20.1;PD11.8,20.1;PU9.2,20.1;PD9.2,20.3;PU10,20.1;PD10,20.3;PU10.9,20.1;PD10.9,20.3;PU11.8,20.1;PD11.8,20.3;"
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| 42 | W !,"PU12.1,20.1;LBTime@;SD1,277,2,1,4,9,5,0,6,5,7,23;PU13.7,20.1;LB:@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 43 | W !,"PU14.5,20.4;EA14.7,20.6;PU14.9,20.4;LBa.m.@;PU14.5,20;EA14.7,20.2;PU14.9,20;LBp.m.@;"
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| 44 | W !,"PU.5,19.7;PD21,19.7;"
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| 45 | W !,"PU.5,19.4;LB28. Date and@;PU3.5,19.4;LBMo.@;PU4.4,19.4;LBDay@;PU5.3,19.4;LBYr.@;PU10.1,19.7;PD10.1,18.4;PU10.2,19.4;"
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| 46 | W !,"LB29. Date employee was last@;"
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| 47 | W !,"PU14.2,19.4;LBMo.@;PU15,19.4;LBDay@;PU16,19.4;LBYr.@;"
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| 48 | W !,"PU1,19.1;LBhour employee's@;PU1,18.8;LBpay stopped@;PU3.4,18.8;PD5.9,18.8;PU3.4,18.8;PD3.4,19;PU4.2,18.8;PD4.2,19;PU5.1,18.8;PD5.1,19;PU5.9,18.8;PD5.9,19;"
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| 49 | W !,"PU6.3,18.8;LBTime@;SD1,277,2,1,4,9,5,0,6,5,7,23;PU7.7,18.8;LB:@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 50 | W !,"PU8.5,19.1;EA8.7,19.3;PU8.9,19.1;LBa.m.@;PU8.5,18.7;EA8.7,18.9;PU8.9,18.7;LBp.m.@;"
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| 51 | W !,"PU10.6,19.1;LBexposed to conditions@;PU10.6,18.8;LBalleged to have caused@;PU10.6,18.5;LBdisease or illness@;"
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| 52 | W !,"PU14.1,18.8;PD16.7,18.8;PU14.1,18.8;PD14.1,19;PU14.9,18.8;PD14.9,19;PU15.8,18.8;PD15.8,19;PU16.7,18.8;PD16.7,19;PU.5,18.4;PD21,18.4;"
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| 53 | W !,"PU.5,18.4;PD21,18.4;PU.5,18.1;LB30. Date@;PU2.6,18.1;LBMo.@;PU3.5,18.1;LBDay@;PU4.5,18.1;LBYr.#"
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| 54 | W !,"PU1.1,17.8;LBreturned@;PU1.1,17.5;LBto work@;PU2.5,17.5;PD5.1,17.5;PU2.5,17.5;PD2.5,17.7;PU3.3,17.5;PD3.3,17.7;PU4.2,17.5;PD4.2,17.7;"
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| 55 | W !,"PU5.1,17.5;PD5.1,17.7;PU5.4,17.5;LBTime@;SD1,277,2,1,4,9,5,0,6,5,7,23;PU6.9,17.5;LB:@;SD1,277,2,1,4,9,5,0,6,0,7,16901;"
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| 56 | W !,"PU7.8,17.7;EA8,17.9;PU8.2,17.7;LBa.m.@;PU7.8,17.3;EA8,17.5;PU8.2,17.3;LBp.m.@;"
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| 57 | W !,"PU.5,17.1;PD21,17.1;PU.5,16.8;LB31. If employee has returned to work and work assignment has changed, describe new duties@;"
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| 58 | W !,"PU.5,12.6;PD21,12.6;"
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| 59 | W !,"PU.5,12.3;LB32. Was injury caused@;PU3.6,12.6;PD3.6,10.1;PU3.6,11.7;PD21,11.7;PU3.6,10.9;PD21,10.9;"
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| 60 | W !,"PU3.7,12.3;LB33. Name and address of third party (Include city, state, and zip code)@;"
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| 61 | W !,"PU.9,12;LBby third party?@;PU.9,11.5;EA1.1,11.7;PU1.3,11.5;LBYes@;PU2.3,11.5;EA2.5,11.7;PU2.7,11.5;LBNo@;"
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| 62 | W !,"PU2.3,11.2;LBIf ""No,""@;PU2.3,10.9;LBgo to@;PU2.3,10.6;LBitem 34.@;"
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| 63 | W !,"PU.5,10.1;PD21,10.1;PU.5,9.6;PD21,9.6;SD1,277,2,1,4,9,5,0,6,1,7,23;PU.5,9.7;LBSignature of Supervisor@;PU.5,9.6;RA21,10.1;"
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| 64 | W !,"SD1,277,2,1,4,9,5,0,6,0,7,16901;PU.5,9.3;LB34. A supervisor who knowingly certifies to any false statement,@;"
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| 65 | W !,"LB misrepresentation, concealment of fact, etc., in respect to this claim@;"
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| 66 | W !,"PU1.1,8.9;LBmay also be subject to appropriate felony criminal prosecution.@;"
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| 67 | W !,"PU1.1,8.4;LBI certify that the information given above and that furnished by the employee on the reverse@;"
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| 68 | W !,"LB of this form is true to the best of my@;"
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| 69 | W !,"PU1.1,8.1;LBknowledge with the following exception:@;"
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| 70 | W !,"PU.5,6.2;PD21,6.2;PU.5,5.9;LBName of Supervisor (Type or print)@;"
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| 71 | W !,"PU.5,5.4;PD21,5.4;PU.5,5.1;LB Signature of Supervisor@;PU12.4,5.1;LBDate@;"
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| 72 | W !,"PU.5,4.6;PD21,4.6;PU.5,4.3;LBSupervisor's Title@;PU12.4,4.3;LBOffice phone@;"
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| 73 | W !,"PU.5,3;PD21,3;PU19,2.5;SD1,277,2,1,4,9,5,0,6,0,7,16901;LBCA-2@;"
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| 74 | D:IEN>0 ^OOPSPC51
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| 75 | W !,$CHAR(27),"&r0F",$CHAR(27),"%0A" Q
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