Amputation Chart by Zothedamaga

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                Amputation Chart                        The boxes
                                                                       Reserved                  VWC file number

                                                        to the right
    Virginia Workers' Compensation Commission                          Insurer code              Insurer location
                                                        are for the
       1000 DMV Drive Richmond VA 23220                 use of the
                                                                       Insurer claim number
                                                          Insurer

         Employer
Name of employer                                         Date of Accident                     Date of Amputation


         Employee
Name of employee                                         Social Security Number




  Which hand?




         Signature

Chart marked by                                   M.D                     Date
                                                   .
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