FIRST REPORT OF INJURY REFERRAL

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Preparer's Information

Type of Claim:

Report OnlyTelephonic Case MgmtField Case Mgmt

Injured Employee

Employment Status

Full TimePart-TimePer Diem

Marital Status

SingleMarriedDivorcedWidowed

Injury Information

Were there any witnesses?

YesNo

Were There Any Prior Injuries?

YesNo

Is Follow-Up Treatment Needed?