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The first side is typically filled in by your supervisor who will indicate the types of actions you carry out. Office of workers' compensation programs. Fill in the address of the. Specify type, yes no go to section 3 such as downgrade, loss of night differential, etc.
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Complete side a and refer the form to the physician. Fill in the address of the. Web this form provides your supervisor and owcp with interim medical reports containing information as to your ability to return to any type of work.