[604] | 1 | English French Notes Complete/Exclude
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| 2 | INITIAL DOSE..................:
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| 3 | SECOND DOSE...................:
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| 4 | ADJUVANT CHEMO W BEAM RADIATION.:
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| 5 | THYROID HORMONE THERAPY.........:
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| 6 | Date of 1st course of tx....:
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| 7 | Date of 1st Surgical Proc...:
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| 8 | Surgery of primary site F...:
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| 9 | Surgery of primary site @fac F:
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| 10 | Radiation therapy to CNS....:
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| 11 | Hormone therapy.............:
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| 12 | Hormone therapy @fac........:
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| 13 | Other treatment.............:
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| 14 | Other treatment @fac........:
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| 15 | SURGICAL DX/STAGING PROC DATE: 99/99/9999
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| 16 | Unknown;
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| 17 | SURGICAL PROC/OTHER SITE DATE..:
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| 18 | DATE RADIATION STARTED:......:
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| 19 | LOCATION OF RADIATION........:
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| 20 | RADIATION TREATMENT VOLUME...:
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| 21 | REGIONAL TREATMENT MODALITY..:
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| 22 | REGIONAL DOSE:cGy............:
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| 23 | BOOST TREATMENT MODALITY.....:
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| 24 | BOOST DOSE:cGy...............:
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| 25 | NUMBER OF TREATMENTS.........:
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| 26 | DATE RADIATION ENDED.........:
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| 27 | CHEMOTHERAPY DATE:.............:
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| 28 | HORMONE THERAPY DATE:..........:
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| 29 | IMMUNOTHERAPY DATE:............:
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| 30 | HEMA TRANS/ENDOCRINE PROC DATE.:
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| 31 | SURG PROC/OTHER SIT @FAC...(R):
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| 32 | SURGICAL PROC/OTHER SITE @FAC..:
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| 33 | RADIATION @FAC...............:
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| 34 | RADIATION @FAC DATE..........:
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| 35 | CHEMOTHERAPY @FAC..............:
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| 36 | CHEMOTHERAPY @FAC DATE.........:
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| 37 | HORMONE THERAPY @FAC...........:
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| 38 | HORMONE THERAPY @FAC DATE......:
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| 39 | IMMUNOTHERAPY @FAC.............:
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| 40 | IMMUNOTHERAPY @FAC DATE........:
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| 41 | Select case to be amended:
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| 42 | Case number
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| 43 | has been assigned to this amended incident.
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| 44 | Use option
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| 45 | Edit Report of Incident
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| 46 | to complete this case.
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| 47 | NAME OF EMPLOYEE...............:
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| 48 | SSN............................:
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| 49 | DOB............................:
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| 50 | SEX............................:
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| 51 | HOME TELEPHONE.................:
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| 52 | GRADE/STEP.....................:
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| 53 | PAY PLAN.......................:
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| 54 | EMPLOYEE'S ADDRESS.............:
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| 55 | CITY...........................:
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| 56 | STATE..........................:
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| 57 | ZIP............................:
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| 58 | DEPENDENTS.....................:
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| 59 | PLACE WHERE INJURY OCCURRED....:
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| 60 | STREET WHERE INJURY OCCURRED...:
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| 61 | CITY WHERE INJURY OCCURRED.....:
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| 62 | STATE WHERE INJURY OCCURRED....:
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| 63 | ZIP CODE WHERE INJURY OCCURRED.:
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| 64 | DATE/TIME OF OCCURRENCE........:
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| 65 | DATE OF THIS NOTICE............:
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| 66 | EMPLOYEE'S OCCUPATION..........:
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| 67 | CAUSE OF INJURY CODE...........:
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| 68 | CAUSE OF INJURY................:
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| 69 | NATURE OF INJURY...............:
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| 70 | REQUEST PAY OR LEAVE...........:
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| 71 | EMPLOYEE DATE OF SIGNATURE.....:
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| 72 | WITNESS INFORMATION:
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| 73 | NAME OF WITNESS................:
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| 74 | WITNESS ADDRESS................:
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| 75 | WITNESS CITY...................:
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| 76 | WITNESS STATE..................:
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| 77 | WITNESS ZIP CODE...............:
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| 78 | DATE OF WITNESS SIGNATURE......:
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| 79 | STATEMENT OF WITNESS...........:
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| 80 | OCCUPATION CODE................:
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| 81 | NOI CODE.......................:
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| 82 | TYPE CODE......................:
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| 83 | SOURCE CODE....................:
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| 84 | OWCP CHARGEBACK CODE...........:
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| 85 | AGENCY NAME....................:
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| 86 | AGENCY ADDRESS.................:
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| 87 | AGENCY CITY....................:
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| 88 | AGENCY STATE...................:
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| 89 | AGENCY ZIP CODE................:
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| 90 | EMPLOYEE'S DUTY STATION........:
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| 91 | DUTY STATION ADDRESS...........:
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| 92 | DUTY STATION CITY..............:
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| 93 | DUTY STATION STATE.............:
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| 94 | DUTY STATION ZIP CODE..........:
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| 95 | EMPLOYEE RETIREMENT COVERAGE...:
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| 96 | EMP RETIREMENT COVERAGE DESC...:
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| 97 | REGULAR HRS FROM TIME..........:
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| 98 | REGULAR HRS TO TIME............:
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| 99 | REGULAR WORK SCHEDULE..........:
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| 100 | DATE OF INJURY.................:
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| 101 | DATE NOTICE RECEIVED...........:
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| 102 | DATE/TIME STOPPED WORK.........:
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| 103 | DATE PAY STOPPED...............:
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| 104 | DATE 45 DAY PERIOD BEGAN.......:
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| 105 | DATE/TIME RETURNED TO WORK.....:
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| 106 | INJURED PERFORMING DUTY........:
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| 107 | NOT INJURED PERFORMING JOB.....:
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| 108 | INJURY CAUSED BY EMPLOYEE......:
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| 109 | CAUSED BY EMPLOYEE EXPLAIN.....:
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| 110 | INJURY CAUSED BY 3RD PARTY.....:
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| 111 | 3RD PARTY NAME.................:
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| 112 | 3RD PARTY ADDRESS..............:
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| 113 | 3RD PARTY CITY.................:
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| 114 | 3RD PARTY STATE................:
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| 115 | 3RD PARTY ZIP CODE.............:
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| 116 | PROVIDING PHYSICAN NAME........:
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| 117 | PROVIDING PHYSICIAN ADDRESS....:
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| 118 | PROVIDING PHYSICIAN CITY.......:
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| 119 | PROVIDING PHYSICIAN STATE......:
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| 120 | PROVIDING PHYSICIAN ZIP CODE...:
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| 121 | PROVIDING PHYSICIAN TITLE......:
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| 122 | FIRST DATE OF MEDICAL CARE.....:
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| 123 | DISABLED FOR WORK..............:
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| 124 | SUPERVISOR AGREE/DISAGREE......:
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| 125 | SUPERVISOR NOT AGREE EXPLAIN...:
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| 126 | REASON FOR CONTROVERTS COP.....:
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| 127 | PAY RATE WHEN WORK STOPPED.....:
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| 128 | SUPERVISOR EXCEPTION...........:
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| 129 | NAME OF SUPERVISOR.............:
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| 130 | SUPERVISOR'S DATE OF SIGNATURE.:
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| 131 | SUPERVISOR'S TITLE.............:
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| 132 | SUPERVISOR'S OFFICE PHONE......:
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| 133 | FILING INSTRUCTIONS............:
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| 134 | Case #
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| 135 | ILLNESS OCCURRED (LOCATION)....:
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| 136 | ILLNESS OCCURRED ADDRESS.......:
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| 137 | ILLNESS OCCURRED CITY..........:
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| 138 | ILLNESS OCCURRED STATE.........:
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| 139 | ILLNESS OCCURRED ZIP CODE......:
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| 140 | DATE FIRST AWARE OF ILLNESS....:
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| 141 | DATE FIRST REALIZED CAUSE.......:
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| 142 | RELATIONSHIP OF ILLNESS TO EMP.:
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| 143 | NATURE OF DISEASE/ILLNESS......:
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| 144 | REASON CLAIM NOT FILED.........:
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| 145 | EMPLOYEE STATEMENT DELAY.......:
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| 146 | REASON MEDICAL REPORT DELAYED..:
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| 147 | DATE OF EMPLOYEE SIGNATURE.....:
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| 148 | 1ST PROVIDING PHYSICAN NAME....:
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| 149 | 1ST PROVIDING PHYS. ADDRESS....:
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| 150 | 1ST PROVIDING PHYS. CITY.......:
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| 151 | 1ST PROVIDING PHYS. STATE......:
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| 152 | 1ST PROVIDING PHYS. ZIP CODE...:
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| 153 | 1ST PROVIDING PHYS. TITLE......:
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| 154 | DATE 1ST REPORTED TO SUPERVISOR:
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| 155 | DATE/TIME WORK STOPPED.........:
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| 156 | DATE OF LAST EXPOSURE..........:
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| 157 | WORK DUTY CHANGED..............:
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| 158 | EMP RETIREMENT COVERAGE DESC.:
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| 159 | Case number
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| 160 | will be assigned to this incident.
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| 161 | 2 PERSONNEL STATUS.........
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| 162 | PERSON INVOLVED..........:
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| 163 | No SSN on file in the New Person file. Must enter to create case.
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| 164 | This person (SSN) is a 'PAID' Employee, Please Re-enter
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| 165 | 1 PERSON INVOLVED..........
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| 166 | Social Security Number is Required
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| 167 | Date of Birth is required
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| 168 | Sex is Required
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| 169 | 8 HOME STREET ADDRESS......
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| 170 | Invalid character entered, (~,`,@,#,$,%,*,_,|,\,},{,[,],>, or <),
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| 171 | please edit.
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| 172 | 11 ZIP CODE.................
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| 173 | 12 HOME PHONE NUMBER........
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| 174 | Phone number must include area code and 7 digits only. Example 703-123-8789
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| 175 | 13 STATION NUMBER...........//^S X=STN
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| 176 | 4 DATE/TIME INJURY OCCURRED
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| 177 | 4 DATE 1ST AWARE OF ILLNESS
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| 178 | 3 TYPE OF INCIDENT.........
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| 179 | VOLUNTARY SVC SUPERVISOR.
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| 180 | CONTRACT ADMINISTRATOR...
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| 181 | SAFETY OFFICER...........
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| 182 | 53.1 SECONDARY SUPERVISOR.....
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| 183 | This Case will be DELETED!
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| 184 | Case action
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| 185 | has been saved.
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| 186 | The following case(s) are Open with SSN:
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| 187 | CASE NUMBER:
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| 188 | PERSON INVOLVED:
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| 189 | PERSONNEL STATUS:
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| 190 | PAY PLAN:
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| 191 | TYPE OF INCIDENT:
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| 192 | DATE/TIME OF OCCURRENCE:
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| 193 | INJURY/ILLNESS:
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| 194 | SUPERVISOR:
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| 195 | PERSON ENTERING STUB RECORD:
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| 196 | Is the Current entry a DUPLICATE Case:
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| 197 | VOLUNTARY SVC SUP......:
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| 198 | CONTRACT ADMINISTRATOR.:
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| 199 | SAFETY OFFICER.........:
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| 200 | CASE NUMBER............:
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| 201 | PERSONNEL STATUS.......:
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| 202 | TYPE OF INCIDENT.......:
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| 203 | CASE STATUS............:
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| 204 | PERSON INVOLVED........:
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| 205 | DATE OF BIRTH..........:
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| 206 | HOME ADDRESS...........:
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| 207 | HOME PHONE NUMBER......:
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| 208 | STATION NUMBER.........:
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| 209 | COST CENTER/ORG........:
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| 210 | SECONDARY SUPERVISOR...:
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| 211 | DATE/TIME OF OCCURRENCE:
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| 212 | Print Employee Bill of Rights
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| 213 | EMPLOYEES' BILL OF RIGHTS FOR ACCIDENT AND OCCUPATIONAL ILLNESSES
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| 214 | The Federal Employees' Compensation Act (FECA) describes an employee's
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| 215 | rights and entitlements to benefits following a work-related
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| 216 | injury or illness.
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| 217 | You have the right to file a CA-1 (injury) or CA-2 (illness), to apply
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| 218 | for compensation.
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| 219 | Entitlements include the option to receive medical treatment by either
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| 220 | the VA Employee Health Unit or by your primary care physician.
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| 221 | You have the right to request union representation.
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| 222 | For additional information and explanation of your rights and
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| 223 | responsibilities, contact your Workers' Compensation
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| 224 | Specialist/Coordinator/Manager.
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| 225 | You have the right to select the physician or facility to provide
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| 226 | treatment for the sustained injury or illness. The VA facility is
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| 227 | available for examination and treatment, but cannot mandate use of
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| 228 | the facility to the exclusion of your choice of medical care.
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| 229 | apply for compensation.
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| 230 | You have the right to union representation at any time.
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| 231 | OOPS DOL XMIT DATA
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| 232 | You do not have the required Security Key.
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| 233 | Press Enter to continue
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| 234 | Domain not found in the DOMAIN File,
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| 235 | No Transmission. Press Enter to continue
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| 236 | Re-transmit cases for what date
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| 237 | Enter the date of original transmission for cases
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| 238 | that need to be resent
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| 239 | Enter 'Y' if you want the CA1/CA2 data placed in mail
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| 240 | message as part of a tasked job.
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| 241 | TRANSMIT DOL CA1/CA2 DATA
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| 242 | Transmission NOT queued, OK to continue
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| 243 | The Queue Q-AST.MED.VA.GOV has not been created. Please contact your IRM
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| 244 | Dept. to have Patch XM*999*136 installed; once installed complete manual
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| 245 | transmission of DOL Data.
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| 246 | OOPS WC MESSAGE
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| 247 | The Mail Group OOPS WC MESSAGE is missing.
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| 248 | Add the Group so that ASISTS data can be transmitted
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| 249 | to the AAC. Then contact Worker Compensation office
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| 250 | to complete manual Transmission of DOL Data.
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| 251 | There are no members of the OOPS WC MESSAGE
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| 252 | Mail Group.
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| 253 | Enter at least one member to the group. This person
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| 254 | will receive messages concerning the transmission of
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| 255 | ASISTS DOL data to and from the AAC. After adding member
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| 256 | contact Worker Compensation office to complete manual transmission of DOL data.
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| 257 | No cases to transmit for requested date
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| 258 | ASISTS Report on Daily Transmission to the AAC
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| 259 | ASISTS no claims to process
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| 260 | There were no claims ready for transmission
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| 261 | to the Austin Automation Center when the.
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| 262 | scheduled task last ran.
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| 263 | Mail Message was not created. Contact Worker Compensation office
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| 264 | to complete the transmission of ASISTS DOL data.
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| 265 | ASISTS DOL DATA
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| 266 | XXX@Q-AST.MED.VA.GOV
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| 267 | Case:
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| 268 | has missing required data or word processing fields that are
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| 269 | larger than DOL requirements. Please edit the case(s); and once completed,
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| 270 | the cases will be transmitted with the next scheduled transmission.
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| 271 | ASISTS Record(s) not transmitted for Station
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| 272 | OOPS WCP
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| 273 | The following claims have been transmitted to the AAC:
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| 274 | ASISTS Record(s) transmitted to AAC for Station
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| 275 | ASISTS Package
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| 276 | ASISTS DOL Error Notification Message
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| 277 | An Error Occurred during Processing, check
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| 278 | Mailman Message for details.
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| 279 | PRINT CA FORM
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| 280 | No SSN on file for this Employee
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| 281 | An Accident Report has not been created for this Employee
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| 282 | Select Case:
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| 283 | Claim cannot be signed until the Bill of Rights Statement is understood.
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| 284 | Checking for Safety and Emp Health Ok to sign for Employee.
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| 285 | Please enter a Signature Code.
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| 286 | 71I have read and understood the Employee Bill of Rights:
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| 287 | Notice of Occupational Disease and Claim for Compensation (Form CA-2)
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| 288 | Employee Data
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| 289 | 1. NAME OF EMPLOYEE......:
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| 290 | 2. SOCIAL SECURITY NUMBER:
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| 291 | 3. DATE OF BIRTH.........:
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| 292 | 12 5. HOME TELEPHONE........
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| 293 | 7. EMPLOYEE'S HOME MAILING ADDRESS:
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| 294 | 8 STREET ADDRESS........
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| 295 | 11 ZIP CODE..............
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| 296 | Claim Information
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| 297 | 10. LOCATION WHERE YOU WORKED WHEN DISEASE OR ILLNESS OCCURRED:
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| 298 | 210 STREET ADDRESS........
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| 299 | 213 ZIP CODE..............
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| 300 | 214 11. DATE YOU FIRST BECAME AWARE OF DISEASE OR ILLNESS;I X=
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| 301 | 215 12. DATE YOU FIRST REALIZED THE DISEASE OR ILLNESS WAS CAUSED BY YOUR EMPLOYMENT;I X=
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| 302 | 216 13. EXPLAIN THE RELATIONSHIP TO YOUR EMPLOYMENT, AND WHY YOU CAME TO THIS REALIZATION~
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| 303 | #################### #################### ####################
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| 304 | #################### #################### ####################
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| 305 | #################### #################### ####################
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| 306 | #################### #################### ####################
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| 307 | #################### #################### ####################
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