ࡱ> tvs7 wbjbjUU %N7|7|lpppllll|d \X((((HtoMlN7[9[9[9[9[9[9[$] 2_l][ipO?( HOO][/U((&[/U/U/UO(p(7[/UO7[/U/U7[p7[(L ^W l1R7[7[[0 \7[_1R_7[/U  FORMTEXT     FORMTEXT     FORMTEXT     FORMTEXT       Carrier:  FORMTEXT       Employer:  FORMTEXT        FORMTEXT       Carrier's File No.  FORMTEXT        FORMTEXT       In the event of the death of the employee, this report should be filed immediately.  FORMTEXT       Name of Employer  FORMTEXT       Office address: No. and St  FORMTEXT       City or Town  FORMTEXT        FORMTEXT       Name of Injured (in full)  FORMTEXT        FORMTEXT        FORMTEXT       No. and St  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Date of Injury  FORMTEXT        FORMTEXT       Day of week  FORMTEXT       Hour of day  FORMTEXT        FORMTEXT       Date disability began  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Has injured returned to work?  FORMTEXT       If so, date and hour  FORMTEXT        FORMTEXT       Is injured person earning same wages as before injury?  FORMTEXT       If not, explain  FORMTEXT       If disability has not terminated, state probable date of termination of disability  FORMTEXT       Has injured died?  FORMTEXT       If so, date of death  FORMTEXT        FORMTEXT        FORMTEXT       Date of this report  FORMTEXT       Agency name  FORMTEXT       Signed by  FORMTEXT       Official Title  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        - STANDARD FORM FOR EMPLOYER'S SUPPLEMENTAL REPORT OF INJURY State's File- Number For: (The spaces above not to be filled in by Employer) days. If Employer's First Report of Injury did not show that the injured had returned to work, an Employer's Supplemental Report of Injury should be completed and filed immediately after the return to work of the employee; or at the end of 1. 2. State 3. Injured Employee Social Security No 19/20 4. (First Name (Middle Name) (Last Name) 5. Present address: City or Town State Zip Code 6. 19/20 A.M - 7. A.M. P.M 8. A.M. P.M. 9. 10. 11. AM P.M. 12. Additional information: DA 1974 (Rev. 3-91) PC-1015 P.M.  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