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Patient ID# (Medical Records #) Patient ID# (Medical Records #) Year Patient Name Last First Pregnant? Sex 1 Male 2 Female Y / N Race 1 White 2 Black Date of Birth Mo Day MI Ethnicity 1 Hispanic 2 Non-Hispanic 3 Native American 4 Asian 5 Other Age (if no DOB) Yr Home Zip Code Social Security Number (Last 4) - - Demographic Memo SECTION II INJURY DATA Injury Date Injury Time / : / Place of Injury Zip Code Incident Location Type E849 0 Home 1 Farm 2 Min.

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