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?