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Pennsylvania
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South Carolina
South Dakota
Tennessee
Texas
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Vermont
Virginia
Washington
West Virginia
Wisconsin
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Accident Date / Dia del Accident
*
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Month / Mes
-
Day / Dia
Year / Dia
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Time of Accident / Hora del Accidente
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour / Hora
00
10
20
30
40
50
Minutes / Minutos
AM
PM
AM/PM Option
Employee status / Estatus del Trabajador
Full Time / Tiempo Completo
Part Time / Medio Tiempo
Temporary / Temporal
Accident Classification / Clasificacion del Accidente
Medical Treatment / Tratamiento Medico
First AID only / Primeros Auxilios
Name of Clinic / Nombre de la Clinica
*
Full Name / Nombre Completo
*
First Name / Primer nombre
Last Name / Apellido
Phone Number / Telefono del trabajador
*
Rate x Hr $ / Pago x Hr $
Birthday / Fecha de Nacimiento
*
-
Month / Mes
-
Day / Dia
Year / Año
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SS # or Tax ID
*
Address / Direccion
*
Street Address / Calle
Street Address Line 2 / Calle linea 2
City / Ciudad
State / Province / Estado
Postal / Zip Code / Codigo Postal
Please Select
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American Samoa
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Anguilla
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Netherlands Antilles
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Nigeria
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eSwatini
Sweden
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Tonga
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Vatican City
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US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country / Pais
Name of Project / Nombre del Proyecto
*
Drywall Company / Nombre del Drywall contractors
*
Name Supervisor : / Nombre del Supervisor
*
Type of Accicent / Tipo de Accidente
*
Slip, Fall, Burn, piece lint in Eye, Bite, Cut, Electric
Region / Parte Golpeada
*
Ear Eye Nose Lips Neck Shoulder Fingers Abdomen Foot
Witness Name / Nombre del Testigo
*
What Caused the Accident: / Cual fue causo el accidente
*
Defective Equipment, Error of other, Liquid on hallways, Sharp
Picture ID / Foto de la Identificacion
*
Picture Accident #1 / Foto del Accidente #1
*
Picture Accident #2 / Foto del Accidente #2
Emergency Contact / Contacto de Emergencia
*
First Name / Primer nombre
Last Name / Apellido
Emergency Phone / Telefono de Emergencia
*
Gender / Genero
*
Male / Hombre
Female / Mujer
Marital Status / Estado Matrimonial
*
Single / Soltero
Married / Casado
Married, But withhold at higher single rate. / Casado Pero retiene con la mayor tasa única
Job Occupation / Cual es tu trabajo?
*
Frame Metal
Frame Wood
Hanger Sherock
Finish
acoustic ceiling tiles
Layout (planos)
Stucco
paint comercial
concrete
Cabinets
Cleaning
welder
Tile (Bathroom, kitchen)
Roof (Shingle o Tile)
Injured Own Description / Descripcion del Accidente (Accidentado)
*
Witness Own description / Descripcion del Accidente (Testigo)
*
Signature / Firma
*
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