DISEENSARY PERMIT Ref: I TO DISPENSARY (Enter Location) DATE OF REPORT BADGE NO. SUPERVISOR REPORT r? ?3 I i LJCT .. . r? I NAME TIME OF INJURY LEFT JOB TIME RETURNED . 5! 1 ?\11 A, 9 {newsw.?lsiw . I GRADE, RATE, JOB TITLE OCCUPATIONEL Lef)? ff) YES Cl NO QUESTIONABLE I I i REASON FOR REFERRAL . INJURY Cl ILLNESS Cl EMPLOYEE 5 REQUEST El?- OTHER (Explain) - I I: .r?l-F i? 4 REMARKS 1:115 3:3; i3, 11.51.53 5:7 ?of NO. NUMBER TIME REPORTED TIME RELEASED MEDICAL REPORT .: H: r75 s" i. I Ma?s OCCUPATIONAL DEGREE 0F INJURY I IE FIRST AID MEDICAL TREATMENT YES El NO QUESTIONABLE OTHER (Explain): DISPOSITION OF EMPLOYEE (ism) I 7' TEMP TRANSFER TO ANOTHER JOB I. RESTRICT ACTIVITY UNTIL PERM TRANSFER TO ANOTHER JOB FSENT HOME BY DISPENSARY REFERRED TO PRIVATE OTHER (Explain): - 2 [3 GOVERNMENT TRANSPORT EUR MEDICAL NECESSITY AUTHORIZED. MEDICAL SIGNUTURE f/ff IINITIAL REATMENT DETERMINATION DISCHARGED, TREATMENT COMPLETED REQUIRED STATEMENT Authority: Sl?. S. C. 30-, 3 I Regulations, .sure prompt investigation of occupational injuries, and to initiate any necessary immediate corrective an ion. Routine Use: Routinely used by the activity Occupational Safety and Health Office to perform official duties in investigating mishaps which may have caused occupational injury or illness. Disclosure: Vbluntary. Treatment will be provided without regard to employee's willingness to divulge all or part of the requested information. 5100/742 (Rev. 2-13) i IFDISPENSARY PERMIT Ref: osa?I-z yl TO DISPENSARI (Enter Location) IDATE OF REPORT BADGE NO. REPORT P6M5 02,259,20?94 '75556? TIME 5 DATE OF TIME LEFT JOB TIME RETURNED NAME {Quin Wit 1" I GRADE, RATE, JOB TITLE maxi" p?aw?r YES [3 NO El QUESTIONABLE R56 6! 5 REASON FOR REFERRAL INJURY DILLNESS Cl REQUEST I (Explain): ?xi?cw?f ?ght-Mia ifmgz REMARKS I SUPERVISOR-S NO. TELEPHONE NUMBER 2 ?6 TILE REPORTED TIME RELEASED MEDICAL REPORT 5- :1 9 2014 . a? (m 3?0 i OCCUPATIONAL DEGREE OF INJURY FIRST AID TREATMENT El No MODESTIONABLE El OTHER (Eprain): I DISPOSITION OF EMPLOYEE RETURN TO PERM. JOB TEMP TRANSFER TO ANOTHER JOB TERMINATION OF EMPLOYMENT y. ACTIVITY UNTIL gag-m?ky? PERM TRANSFER To ANOTHER JOB SENT HOME BY UISPENSARY REFERRED TO PRIVATE OTHER (Explain): GOVERNMENT TRANSPORT FOR MEDICAL NECESSITY AUTHORIZED. INITIAL TREATMENT DETERMINATION [j DISCHARGED. TREATMENT COMPLETED PICAL 53? 6 - REQUIRED as; PRIVACY ACT STATEMENT . . Authori y: U;s.d. 301, Departmental Regulations. Principle Purpose: To ensure prompt investigation of occupational injuries, and to initiate any necessary immediate corrective action. Routine Usez- Routinely used by the activity Occupational Safety and Health Office to perform official duties in investigating mishaps which may have caused occupational injury or illness. Disclosure: Voluntary. Treatment will be provided without regard to employee's willingness to divulge all or part of the requested information. 1 IPSNSEIME 5100/742 (Rev. 2-13) DISPENSARY PERMIT Ref: TO DISPENSARY (Enter Location) DATE OP REPORT BADGE No. REPORT [?35qu IMF: [75886] EMPLOYEE-s NAME TIME a DATE OF INJURY TIME LEFT JOB TIME RETURNED KW Inhiba??} GRADE, RATE, JOB TITLE OCCUPATIONAL . . - YES NO CI QUESTIONABLE W5 Supev?waor PF REASON FOR REFERRAL INJURY El ILLNESS REQUEST El OTHER (Explain): . REMARKS I-Deammu?l??wm Clum?uJL @Ek NO. TELEPHONE NUMBER Ag] 5/63 (17" 0376 TIME REPORTED TIME RELEASED MEDICAL MAY 092913: [225% OCCUPATIONAL DEGREE 0F INJURY FIRST AID MEDICAL TREATMENT WYES El NO QUESTIONABLE El OTHER (Explain): DISPOSITION OF EMPLOYEE RETURN TO PERM. My 0 9.21?; CI TEMP TRANSFER TO ANOTHER JOB TERMINATION OF EMPLOYMENT RESTRICT ACTIVITY UNTIL PERM TRANSFER TO ANOTHER JOB El SENT HOME BY DISPENSARY REFERRED To PRIVATE El OTHER (Explain): El GOVERNMENT TRANSPORT FOR MEDICAL NECESSITY AUTHORIZED. MEDICAL INITIAL TREATMENT DETERMINATION SIGN WA TREATMENT COMPLETED RE-TREATMENT REQUIRED PRIVACY ACT STATEMENT Authority: 5 U.S.C. 301, Departmental Regulations. Principle Purpose: To ensure prompt investigation of occupational injuries, and to initiate any necessary immediate corrective action. Routine Use: Routinely used by the activity Occupational Safety and Health Office to perform official duties in investigating mishaps which may have caused occupational injury or illness. Disclosure: Voluntary. Treatment will be provided without regard to employee's willingness to divulge all or part of the requested information. PSNSEIMF 5100/742 (Rev. 2-13)