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Reporting Time at OHC

Injury Time

Injury Description

On Examination Findings

Incident Location

Business Unit	Sub Unit	Section	Sub-Section

Injury

Type	Part	Classification

Procedure

Medicine	Dosage	For Days	Qty	Price Per Unit	Stock	Issued	Total Price

Total Amount :

Medicine Disbursment

Yes

No

Referral

Follow-up

Emergency?

Affected Body Parts

Health Advices

Recommended Tests For Checkup

Additional Precautions