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Date of Injury
Did the injury happen on employer's property?
YesNo
If not, where did it happen?
Did the injury happen in Nevada?
Any other persons injured?
Was a vehicle involved?
Was a piece of machinery or equipment involved?
Did you have surgery?
Name of doctors (if known)
Where were you transported after injury?
Do you presently have an attorney?
Have you ever had an attorney for this injury/claim?
Have you done a recorded statement with anyone?
Do you have a copy of an incident report, police report, or medical records?