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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