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PaPt A (To Be Completed 8y Supervisor) <br />Date of Accident / / <br />Name of <br />Injured <br />Name of <br />Project <br />Did Employee Refuse Treatment? <br />❑ Yes ❑ No <br />Was First Aid Rendered? ❑ Yes ❑ No <br />First Aid given by: <br />qua results de <br />Type of Injury (check all that apply): <br />❑ Laceration ❑ Puncture ❑ Sprain/Strain ❑ Bruise ❑ Burn ❑ Foreign Object ❑ Other (specify): <br />Body Part Injured (check all that apply): <br />❑ Back ❑ Shoulder ❑ Arm ❑ Hand <br />❑ Leg ❑ Foot ❑ Head ❑ Face ❑ Eye ❑ Other (specify): <br />Part B (To Be Completed By Injured) <br />I, have refused the professional medical treatment offered tome <br />(name) <br />for the on the job injury which occurred on . This decision is made voluntarily and without <br />(date of Injury) <br />inducement or compulsion. I am releasing Superior Landscaping and Lawn Service from any liability resulting from <br />my refusal of <br />professional medical treatment for this injury <br />or - <br />1L] <br />(el Hombre) <br />herida en el trabajo que ocurri6 <br />he rehusado el tratamientc mBdico profesional ofrecidb a mi para la <br />He tornado esta decision voluntariamente <br />(la fecha de la herida) <br />y sin incentivo u obligaci6n. Libero a la Compania Superior Landscaping and Lawn Serv <br />haber negado tratamientc medico profesional para esta herida. <br />Employee Signature: <br />Superintendent <br />Date: <br />ice de cualquier <br />esponsabilidad <br />qua results de <br />haber negado tratamientc medico profesional para esta herida. <br />Employee Signature: <br />Superintendent <br />Date: <br />