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Get USCG YARD CLINIC REPORT

INJURY SICK CALL/ILLNESS PHYSICAL EXAM SAFETY GLASSES 7. DATE 3. BADGE NUMBER 4. SHOP AND PHONE EXT. 5. OCCUPATION 6. SOCIAL SECURITY NUMBER 8. TIME OUT 10. SHOP SUPERVISOR 9. TIME IN 11. DESCRIPTION OF INJURY TIME, DATE, LOCATION, AND NAME OF WITNESS Clinic to complete blocks 12 through 21 12. ARRIVED AT CLINIC: 13. DEPARTED CLINIC: 14. DIAGNOSIS 16. MEDICAL RESTRICTIONS 15. DUTY STATUS: FIT FOR FULL JURY FIT FOR RESTRICTED DUTY NOT FIT FOR DUTY DURATION OF DUTY STATUS.

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