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If an employee suffers a work-related injury or illness, he or she may be entitled to workers' compensation benefits. Give this form to the employee and have them complete the "Employee" section and then return the form to you. Give the employee the copy marked "Employee's Temporary Receipt," providing the employee with a dated copy when you have completed the form. All employees should also have received a pamphlet describing workers' compensation benefits and procedures to obtain them. This form has been made available by the Department of Industrial Relations for use with non-English speaking employees.
