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u <br />ORONAI.—MAIN OffCE COPY <br />SUPERVISOR'S REPORT OF ACCIDENT <br />REPORTS DEL SUPERVISOR DE UN ACCIDENTE <br />Et QvisiodD�rician <br />Name of k*oedfNmbm Del Lesionado <br />Social Security NumbertNunero Del Seguro Soca) OccuPaborvocupaldon <br />Date of Accidenwscha Del Au tie 19 HaxMora A.M. <br />19 P.M. <br />Name and Address of PfysiciaNNortWre Y Direccion Del Doctor <br />Nature of k*AY Chase De Ao6derte <br />Did leave WoKNLSe Fue Del lab* EI Lesaawdo? Date 19 Hoer A.M. <br />Fecha 19 Hora P.M. <br />Did Injured Return to WoKNLRegrow At Trabajo EI Lawonado? Date 19 How A.M. <br />Fecha 19 Hoa P.M. <br />Was Injured Acting in Regular Line of DutyW4Se Ocupaba En Su Pt>esto Regula(? <br />Where Did Accident O=n N iDo de Sino Et AccideMe? <br />How Did Accident OuxuYN 1.Camo Suxedio EI Acadente? <br />What steps should be talm to prevent a sirdar accident? <br />?Ohre Debeda De Hader Prevww un Ac to SurtAaR <br />DatefFecha Supervisors SigrahxuYFama Del Supervisor <br />STATE COMPENSATION INSURANCE FUND <br />SCIF Forth 17609 (Wvmd lOa4 <br />