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Get and Sign STATE of CALIFORNIA DWC DISTRICT OFFICE 2020-2022 Form
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ADJ
DEU
SIF
UEF
SAU
INT
RSU
Companion Cases
Specific Injury
Case Number 2
Cumulative Injury
(Start Date: MM/DD/YYYY)
(End Date: MM/DD/YYYY)
(If Specific Injury, use the start date as the specific date of injury)
Body Part 1:
Body Part 3:
Body Part 2:
Body Part 4:
Other Body Parts:
DWC-CA form 10232.1 Rev. 5/2020 - Page 1 of 8
Specific Injury
Case Number 3
Cumulative Injury
(Start Date: MM/DD/YYYY)
(End Date: MM/DD/YYYY)
(If Specific Injury, use the...
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