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C <br />C <br />ORIGINAL—MAIN OFFICE Copy <br />SUPERVISOR'S REPORT OF ACCIDENT <br />E E DEL SUPERVISOR DE <br />Empioyer/p�ron UN ACCIDENTE <br />ahsioND,,cion <br />Name of Injured/Nombre Del <br />Lesiontt� <br />Social S0cudh NumberMurr>ero DN Sego Social <br />Occupation/o,,ci <br />Date of Accident/Fecha Del Aociderae <br />19 HourMora A.M. <br />19 <br />NamY�cian/Ne and Address of Ph P.M. <br />omtae Y Direcciar Del Doctor <br />Nature of lryury/Ctasa <br />De Accidents <br />Did lNured Leave W0rk7/lSe Fu& <br />Del Trabajo EI Lesionado? Date <br />Did Injured Return Fecha 19 Hour A.M. <br />to WorK?/iRegreso PJ Tmba19 Hom P.M. <br />lo E/ Leslona O? Date <br />Fecha 19 Hou. A.M. <br />Was Injured Acting in Re 19 Hors P.M. <br />pular Lina of put�j4Se �upaba En Su P <br />uesto Regular? <br />Where Did Accident Occur?/ iDonde Sucedio EI <br />AccideMe? <br />How Did Accident OccuR/ZComo S <br />urardio El ,gcpdarW <br />Whet steps Sf Wd be taken to preva <br />?Quo Daberia De Hacer Prevenir sim lar accident? <br />un era Acciderue Simile// <br />D�e/Fecha <br />Supervisort SignaturfWirma DN Supervisor <br />STATE COMPENSATION INSURANCE <br />SCIF Form 178p9 (Revised 1ov) RANGE FUND <br />