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ORIGINAL.—MAIN OFFICE COPY <br />SUPERVISOR'S REPORT OF ACCIDENT <br />REPORTE DEL SUPERVISOR DE UN ACCIDENTE <br />Empbye<(Patron 0Ms*n/DMc*n <br />Name d 14modNannbre Del Lesimado <br />How Did Accident Occuff Xomo Sucedo EI Aecidente? <br />What steps should be taken to prevent a swrmW accudeni? <br />?Oue Debella De Hacer Prevenir urn Accidente Stn W. <br />DaWFocha Supervisors SignaturelFrma Del Supervisor <br />STATE COMPENSATION INSURANCE FUND <br />SCIF Farm IM9 (Revised W- <br />11 <br />Social Security Number/Numero Del Segwo Social Occupy icNOcupadon <br />Date of AcddenUFecha DelAcddente 19 HoudHora <br />A.M. <br />19 <br />P.M. <br />Name and Address d Ptrpmn/Nombre Y Dwecdon Del Doctor <br />Nature d Injury/C7ase De Accidente <br />Did Injured leave WwOLSe Fue Del Trabajo EI Lemonado? Date <br />19 Hour A.M. <br />Fedor <br />Did Injured Return to WbrK44Regreso At Trabajo EI Lesionado? Date <br />19 Hoa P.M. <br />19 Hour A.M. <br />Fecha <br />19 Hora P.M. <br />Was Injured Acting in Regular Line of DutyWLSe Ocupaba En Su Puesto Regular? <br />Where Did Accident OccurW Monde Suo%W EI Ardente? <br />How Did Accident Occuff Xomo Sucedo EI Aecidente? <br />What steps should be taken to prevent a swrmW accudeni? <br />?Oue Debella De Hacer Prevenir urn Accidente Stn W. <br />DaWFocha Supervisors SignaturelFrma Del Supervisor <br />STATE COMPENSATION INSURANCE FUND <br />SCIF Farm IM9 (Revised W- <br />11 <br />