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Name of your supervisor*
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When did your supervisor find out?*
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How did your supervisor find out?*
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When have you received medical care for your work injury?*
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Where have you received medical care for your work injury?*
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How long have you worked for this employer?*
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Looking back over the last year, with this employer:
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What was your average wage?*
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What number of hours did you work per week?*
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When injured, were you working for any other employer?
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If so, what was the employer’s name?
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If so, what were your job duties?
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