| 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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