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EMPLOYEE'S NOTICE OF INJURY OR OCCUPATIONAL DISEASE Federal Eniployeus' Compensation Act

This notice should he suhmittel to the immediate superior by an injurel civil employee of the Tederal Covernment. or bs somtone ua bis hehatf, wahta is kours attrr tbe injury. Natice may be givea citier persaaatly or dy mail, H sivld be retained hy tke tilciat supetior untess the iajury cau-es disability fur sork bvont the day or shiit when iniurr ocratred. or tesalts in any cbarge again-t the liereau tor meditcal expease. wi-en ishonid he forwarded to the U'. S. DElAlTNlNT OF LAliOl, Burcan ot Latioyers' Cumpeusation, together wuhthe  ticial superior's report of iajury, Fora C A. 2. Hefore conpensation is paid, wriltea cluia on lucm C. A. 4 must be submitted to the lutrau.

. Date of this notice 27ovebor, 1053

1. I hereby certify that I am employed as a Samisg.Piocheist (Occupation)

at theSo Divdsion,\_Cald Piolomical Tahezetonias (Ph o mann W
and on \_fri2 22-12 19.53, atuu m. (iizy of svec) (Date) (llour. s. m.,or p. m.)
I was injured in the performance of my duties at afceof.wa (Locatinn vhere injury eccurtd)

Cause of injury (Ihsrzile »s Lst )vu can bow and-why injury oturted)

. Nature of injury Classifed I (Neme lart vf.bvy astectad-[racturrd lels lee, bevierd ricài themb, eie.)

Names of witnesstoijury t. Ccf. V. .Ruu

. If this notice was not given within 18 hours afterthe injury, explain reason for delay and state name Resuild
-

This injury was no; caused by my willfuel misconduct, intention to bring about the injury or death of yself or of anouher.nor by my intoxication, and I hereby make clain fur ccmpensation and medical eatnent to which 1 may be entitled by reason of the injury sustaired by me.

Name M.CO.V.L.RU Clson
Address jar:lend (Steeet and number)

(Cily er san)

(Sute)