GLOBAL MAP DATA DICTIONARY #2260 -- ASISTS ACCIDENT REPORTING FILE 3/24/25 PAGE 1
STORED IN ^OOPS(2260, *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 2.0)
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This file contains all information associated with an accident that results in injury and/or illness.
CROSS
REFERENCED BY: PERSONNEL STATUS(AC), DATE/TIME OF OCCURRENCE(AD), INCLUDE ON OSHA LOG(AE), NEEDS XMIT TO NDB(AN),
DATE TRANSMITTED TO NDB(ANC), TRANSMIT TO WCMIS(AW), DATE TRANSMITTED TO WCMIS(AWC), CASE NUMBER(B),
CASE NUMBER(BS5), SSN(BS5), PERSON INVOLVED(C), STATION NUMBER(D), SSN(SSN)
INDEXED BY: DATE/TIME OF OCCURRENCE & INCLUDE ON OSHA LOG (AF)
^OOPS(2260,D0,0)= (#.01) CASE NUMBER [1F] ^ (#1) PERSON INVOLVED [2F] ^ (#2) PERSONNEL STATUS [3S] ^ (#3) TYPE OF INCIDENT
==>[4P:2261.2] ^ (#4) DATE/TIME OF OCCURRENCE [5D] ^ (#51) CASE STATUS [6S] ^ (#52) INJURY/ILLNESS [7S] ^ (#53)
==>SUPERVISOR [8P:200] ^ (#53.1) SECONDARY SUPERVISOR [9P:200] ^ (#56) PERSON ENTERING STUB RECORD [10P:200] ^
==>(#57) DATE TRANSMITTED TO NDB [11D] ^ (#58) REASON FOR DELETION [12F] ^ (#63) PAY PLAN [13F] ^ (#71) EMPLOYEE
==>BILL OF RIGHTS OK [14S] ^ (#72) EMPLOYEE CONSENT [15S] ^ (#73) OWCP DISTRICT OFFICE [16P:2262.1] ^ (#86)
==>SERVICE [17P:49] ^ (#54) NEEDS XMIT TO NDB [18D] ^ (#59) TRANSMITTED TO NDB [19S] ^ (#90) DATE/TIME STUB
==>CREATED [20D] ^ ^ (#335) TIME WORK BEGAN [22F] ^
^OOPS(2260,D0,2162A)= (#5) SSN [1F] ^ (#6) DATE OF BIRTH [2D] ^ (#7) SEX [3S] ^ (#8) HOME STREET ADDRESS [4F] ^ (#9) CITY [5F] ^
==>(#10) STATE [6P:5] ^ (#11) ZIP CODE [7F] ^ (#12) HOME PHONE NUMBER [8F] ^ (#13) STATION NUMBER [9P:4] ^
==>(#14) COST CENTER/ORGANIZATION [10F] ^ (#15) OCCUPATION [11F] ^ (#16) GRADE [12F] ^ (#17) STEP [13F] ^
==>(#18) EDUCATION [14F] ^ (#19) HEPATITIS B [15S] ^ (#20) HEPATITIS C [16S] ^ (#21) HIV [17S] ^ (#22) OTHER
==>[18S] ^ (#23) DATE ORDERED [19D] ^ (#24) DATE DRAWN [20D] ^ (#25) FOLLOW-UP DATE [21D] ^ (#89) FATALITY
==>[22S] ^ (#333) DATE OF DEATH [23D] ^ (#336) HIRE DATE [24D] ^
^OOPS(2260,D0,2162B)= (#26) GENERAL SETTING OF INCIDENT [1S] ^ (#27) LOCATION OF INJURY [2P:2261.4] ^ (#29) CHARACTERIZATION OF
==>INJURY [3P:2261] ^ (#30) BODY PART MOST AFFECTED [4P:2261.1] ^ (#31) SIDE OF BODY AFFECTED [5S] ^ (#32)
==>DUTY RETURNED TO [6S] ^ (#33) LOST TIME [7S] ^ (#30.1) ADDITIONAL BODY PART AFFECTED [8P:2261.1] ^ (#29.5)
==>MEDICAL EMERGENCY [9S] ^ (#82) BRAND [10P:2262.3] ^ (#83) DEVICE SIZE [11P:2262.2] ^ (#84) SAFETY
==>CHARACTERISTICS [12P:2261.9] ^ (#87) INJ PRIOR TO SAFE DEV ENGAGED [13S] ^ (#88) INCLUDE ON OSHA LOG [14S]
==>^ (#334) ILLNESS TYPE [15S] ^ (#348) LOCATION DETAIL [16F] ^
^OOPS(2260,D0,2162C,0)=^2260.028^^ (#28) DESCRIPTION OF INCIDENT
^OOPS(2260,D0,2162C,D1,0)= (#.01) DESCRIPTION OF INCIDENT [1W] ^
^OOPS(2260,D0,2162D)= (#34) PATIENT SOURCE [1S] ^ (#35) CONTAMINATION [2S] ^ (#36) PURPOSE OF SHARP OBJECT [3P:2261.5] ^ (#37)
==>ACTIVITY AT TIME OF INJURY [4P:2261.6] ^ (#38) OBJECT CAUSING INJURY [5P:2261.7] ^ (#41) BODILY FLUID
==>EXPOSURE SOURCE [6P:2261.8] ^ (#42) EQUIPMENT/DEVICE FAILURE [7F] ^ (#43) SAFETY DESIGN DEVICE USED [8S] ^
==>(#42.5) EQUIP/DEVICE FAILURE OCCURRED [9S] ^ (#337) PRIVACY CASE [10S] ^ (#338) NON VA ER TREATMENT RCVD
==>[11S] ^ (#339) HOSPITALIZED AS INPATIENT [12S] ^ (#340) TREATING PHYSICIAN [13F] ^
^OOPS(2260,D0,2162E,0)=^2260.039SA^^ (#39) AREA EXPOSED TO BODILY FLUID
^OOPS(2260,D0,2162E,D1,0)= (#.01) AREA EXPOSED TO BODILY FLUID [1S] ^
^OOPS(2260,D0,2162ES)= (#44) SUPERVISOR [1P:200] ^ (#45) SUPERVISOR ELECTRONIC SIG [2F] ^ (#46) SUPERVISOR SIGNATURE DATE [3D] ^
==>(#48) SAFETY OFFICER NAME [4P:200] ^ (#49) SAFETY OFF. ELECT. SIGNATURE [5F] ^ (#50) SAFETY OFF. DATE
==>SIGNED [6D] ^
^OOPS(2260,D0,2162F,0)=^2260.01PA^^ (#40) PERSONAL PROTECTIVE EQUIPMENT
^OOPS(2260,D0,2162F,D1,0)= (#.01) PERSONAL PROTECTIVE EQUIPMENT [1P:2261.3] ^
^OOPS(2260,D0,2162G,0)=^2260.047^^ (#47) CORRECTIVE ACTION
^OOPS(2260,D0,2162G,D1,0)= (#.01) CORRECTIVE ACTION [1W] ^
^OOPS(2260,D0,2162H,0)=^2260.055^^ (#55) SAFETY OFF. COMMENTS
^OOPS(2260,D0,2162H,D1,0)= (#.01) SAFETY OFF. COMMENTS [1W] ^
^OOPS(2260,D0,2162L)= (#341) TREATED AT DIFFERENT FACILITY [1S] ^ (#342) OTHER FACILITY NAME [2F] ^ (#343) OTHER FACILITY STREET
==>[3F] ^ (#344) OTHER FACILITY CITY [4F] ^ (#345) OTHER FACILITY STATE [5P:5] ^ (#346) OTHER FACILITY ZIP
==>[6F] ^ (#349) LOSS OF CONSCIOUSNESS [7S] ^ (#350) PRESCRIPTION STRGTH MEDS GIVEN [8S] ^ (#351) NON-SCRIPT
==>MEDS AT SCRIPT DOSE [9S] ^ (#352) INITIAL RETURN TO WORK STATUS [10S] ^
^OOPS(2260,D0,2162M)= (#354) WEATHER FACTOR [1P:2261.21] ^ (#355) SOURCE OF INCIDENT [2P:2261.22] ^ (#356) CAUSE OF INCIDENT [3S]
==>^ (#357) ADDITIONAL CAUSE OF INCIDENT [4S] ^ (#358) PREVENTIVE METHOD [5P:2261.24] ^ (#359) STATUS OF
==>CORRECTIVE ACTION [6S] ^ (#360) SEVERITY OF INJURY [7S] ^
^OOPS(2260,D0,2162R)= (#384) OSHA 300 COLUMN F [1F] ^
^OOPS(2260,D0,2162S)= (#85) SAFETY DEVICE NOT USED [1F] ^
^OOPS(2260,D0,CA)= (#126) CAUSE OF INJURY CODE [1P:2263.2] ^ (#70) OWCP CHARGEBACK CODE [2P:2263.6] ^ (#62) NOI CODE [3P:2263.3]
==>^ (#60) EMP RETIREMENT COVERAGE [4S] ^ (#61) EMP RETIREMENT COVERAGE DESC [5F] ^ (#66) DATE TRANSMITTED TO
==>WCMIS [6D] ^ (#74) VALIDATION CODE [7N] ^ (#199) WORKER'S COMP EDIT [8S] ^ (#75) VALIDATION VERSION [9N] ^ ^
==>^ ^ ^ ^ ^ ^ (#330) OWCP SUFFIX [17F] ^ (#331) OWCP CODE (6 CHARACTER) [18F] ^
^OOPS(2260,D0,CA1A)= (#100) HOME PHONE NUMBER [1F] ^ (#101) GRADE/LEVEL DATE OF INJURY [2F] ^ (#102) STEP AS OF DATE OF INJURY
==>[3F] ^ (#103) EMPLOYEE STREET ADDRESS [4F] ^ (#104) EMPLOYEE CITY ADDRESS [5F] ^ (#105) EMPLOYEE STATE
==>ADDRESS [6P:5] ^ (#106) EMPLOYEE ZIP CODE [7F] ^ (#107) DEPENDENTS [8S] ^ (#108) PLACE WHERE INJURY OCCURRED
==>[9F] ^ (#109) DATE/TIME INJURY OCCURRED [10D] ^ (#110) DATE OF THIS NOTICE [11D] ^ (#111) OCCUPATION [12F] ^
==>(#114) REQUEST PAY OR LEAVE [13S] ^ (#181) ZIP CODE WHERE INJURY OCCURRED [14F] ^
^OOPS(2260,D0,CA1B)= (#112) CAUSE OF INJURY [1F] ^ (#122) OCCUPATION CODE [2F] ^ (#123) TYPE CODE [3P:2263] ^ (#124) SOURCE CODE
==>[4P:2263.1] ^
^OOPS(2260,D0,CA1C)= (#113) NATURE OF INJURY [1F] ^
^OOPS(2260,D0,CA1D)= (#115) NAME OF WITNESS [1F] ^ (#116) WITNESS ADDRESS [2F] ^ (#117) DATE OF WITNESS SIGNATURE [3D] ^ (#116.1)
==>WITNESS CITY [4F] ^ (#116.2) WITNESS STATE [5P:5] ^ (#116.3) WITNESS ZIP CODE [6F] ^
^OOPS(2260,D0,CA1E,0)=^2260.0118^^ (#118) STATEMENT OF WITNESS
^OOPS(2260,D0,CA1E,D1,0)= (#.01) STATEMENT OF WITNESS [1W] ^
^OOPS(2260,D0,CA1ES)= (#119) NAME OF EMPLOYEE [1P:200] ^ (#120) EMPLOYEE ELECT. SIGNATURE [2F] ^ (#121) EMPLOYEE DATE OF
==>SIGNATURE [3D] ^ (#169) NAME OF SUPERVISOR [4P:200] ^ (#170) SUPERVISOR ELECT. SIGNATURE [5F] ^ (#171)
==>SUPERVISOR DATE OF SIGNATURE [6D] ^
^OOPS(2260,D0,CA1F)= (#130) AGENCY NAME [1F] ^ (#131) AGENCY ADDRESS [2F] ^ (#132) AGENCY CITY [3F] ^ (#133) AGENCY STATE [4P:5]
==>^ (#134) AGENCY ZIP CODE [5F] ^ (#135) OWCP CODE [6F] ^ (#136) OSHA SITE CODE [7F] ^ ^ (#138) REGULAR HRS
==>FROM TIME [9F] ^ (#139) REGULAR HRS TO TIME [10F] ^ (#140) REGULAR WORK SCHEDULE [11F] ^ (#141) DATE OF
==>INJURY [12D] ^ (#142) DATE/TIME WORK STOPPED [13D] ^
^OOPS(2260,D0,CA1G)= (#143) DATE PAY STOPPED [1D] ^ (#144) DATE 45 DAY PERIOD BEGAN [2D] ^ (#145) DATE/TIME RETURNED TO WORK [3D]
==>^ (#146) INJURED PERFORMING DUTY [4S] ^ (#147) NOT INJURED PERFORMING JOB [5F] ^ (#148) INJURY CAUSED BY
==>EMPLOYEE [6S] ^ (#149) CAUSED BY EMPLOYEE EXPLAIN [7F] ^ (#150) INJURY CAUSED BY 3RD PARTY [8S] ^
^OOPS(2260,D0,CA1H)= (#151) 3RD PARTY NAME [1F] ^ (#152) 3RD PARTY ADDRESS [2F] ^ (#153) 3RD PARTY CITY [3F] ^ (#154) 3RD PARTY
==>STATE [4P:5] ^ (#155) 3RD PARTY ZIP CODE [5F] ^
^OOPS(2260,D0,CA1I)= (#156) PHYSICIAN NAME [1F] ^ (#157) PHYSICIAN ADDRESS [2F] ^ (#158) PHYSICIAN CITY [3F] ^ (#159) PHYSICIAN
==>STATE [4P:5] ^ (#160) PHYSICIAN ZIP CODE [5F] ^ (#161) FIRST DATE MEDICAL CARE [6D] ^ (#162) DISABLED FOR
==>WORK [7S] ^ (#163) SUPERVISOR AGREE/DISAGREE [8S] ^ (#182) PHYSICIAN TITLE [9P:2263.5] ^ (#165.1) AGENCY
==>CONTROVERT [10S] ^ (#165.2) AGENCY DISPUTE [11S] ^ (#332) AGENCY CONTROVERTS CODE [12P:2262.4] ^ (#347)
==>REASON FOR DISPUTE CODE [13P:2262.8] ^
^OOPS(2260,D0,CA1J,0)=^2260.0164^^ (#164) SUPERVISOR NOT AGREE EXPLAIN
^OOPS(2260,D0,CA1J,D1,0)= (#.01) SUPERVISOR NOT AGREE EXPLAIN [1W] ^
^OOPS(2260,D0,CA1K,0)=^2260.0165^^ (#165) REASON AGENCY CONTROVERTS COP
^OOPS(2260,D0,CA1K,D1,0)= (#.01) REASON AGENCY CONTROVERTS COP [1W] ^
^OOPS(2260,D0,CA1L)= (#166) PAY RATE DOLLAR [1N] ^ (#167) PAY RATE PER [2S] ^ (#168) SUPERVISOR EXCEPTIONS [3F] ^ (#172)
==>SUPERVISOR TITLE [4F] ^ (#173) SUPERVISOR OFFICE PHONE [5F] ^ (#174) FILING INSTRUCTIONS [6S] ^ (#175) DATE
==>NOTICE RECEIVED [7D] ^ (#173.1) SUPERVISOR PHONE EXT [8F] ^
^OOPS(2260,D0,CA1M)= (#176) EMPLOYEE DUTY STATION [1F] ^ (#177) DUTY STATION ADDRESS [2F] ^ (#178) DUTY STATION CITY [3F] ^
==>(#179) DUTY STATION STATE [4P:5] ^ (#180) DUTY STATION ZIP CODE [5F] ^
^OOPS(2260,D0,CA1N)= (#183) INJURY OCCURRED ADDRESS [1F] ^ (#184) INJURY OCCURRED CITY [2F] ^ (#185) INJURY OCCURRED STATE [3P:5]
==>^
^OOPS(2260,D0,CA1W,0)=^2260.0125A^^ (#125) WITNESS NAME
^OOPS(2260,D0,CA1W,D1,0)= (#.01) WITNESS NAME [1F] ^ (#1) WITNESS ADDRESS [2F] ^ (#2) WITNESS CITY [3F] ^ (#3) WITNESS STATE
==>[4P:5] ^ (#4) WITNESS ZIP CODE [5F] ^ (#5) DATE OF WITNESS SIGNATURE [6D] ^
^OOPS(2260,D0,CA1W,D1,1)= (#6) WITNESS STATEMENT [1F] ^
^OOPS(2260,D0,CA2A)= (#200) HOME PHONE NUMBER [1F] ^ (#201) GRADE AS OF LAST EXPOSURE [2F] ^ (#202) STEP AS OF DATE OF ILL. [3F]
==>^ (#203) EMPLOYEE STREET ADDRESS [4F] ^ (#204) EMPLOYEE CITY ADDRESS [5F] ^ (#205) EMPLOYEE STATE ADDRESS
==>[6P:5] ^ (#206) EMPLOYEE ZIP CODE [7F] ^ (#207) DEPENDENTS [8S] ^ (#208) EMPLOYEE OCCUPATION [9F] ^
^OOPS(2260,D0,CA2B)= (#209) ILLNESS OCCURRED (LOCATION) [1F] ^ (#210) ILLNESS OCCURRED ADDRESS [2F] ^ (#211) ILLNESS OCCURRED
==>CITY [3F] ^ (#212) ILLNESS OCCURRED STATE [4P:5] ^ (#213) ILLNESS OCCURRED ZIP CODE [5F] ^ (#214) DATE FIRST
==>AWARE OF ILLNESS [6D] ^ (#215) DATE FIRST REALIZED CAUSE [7D] ^ (#224) OCCUPATION [8F] ^ (#225) OWCP USE NOI
==>CODE [9F] ^ (#226) TYPE CODE [10P:2263] ^ (#227) SOURCE CODE [11P:2263.1] ^
^OOPS(2260,D0,CA2C,0)=^2260.0216^^ (#216) RELATIONSHIP OF ILLNESS TO EMP
^OOPS(2260,D0,CA2C,D1,0)= (#.01) RELATIONSHIP OF ILLNESS TO EMP [1W] ^
^OOPS(2260,D0,CA2D,0)=^2260.0217^^ (#217) NATURE OF DISEASE/ILLNESS
^OOPS(2260,D0,CA2D,D1,0)= (#.01) NATURE OF DISEASE/ILLNESS [1W] ^
^OOPS(2260,D0,CA2E,0)=^2260.0218^^ (#218) CLAIM NOT FILED
^OOPS(2260,D0,CA2E,D1,0)= (#.01) CLAIM NOT FILED [1W] ^
^OOPS(2260,D0,CA2ES)= (#221) NAME OF EMPLOYEE [1P:200] ^ (#222) EMPLOYEE ELECT. SIGNATURE [2F] ^ (#223) DATE OF EMPLOYEE
==>SIGNATURE [3D] ^ (#265) NAME OF SUPERVISOR [4P:200] ^ (#266) SUPERVISOR ELECT. SIGNATURE [5F] ^ (#267)
==>SUPERVISOR DATE OF SIGNATURE [6D] ^
^OOPS(2260,D0,CA2F,0)=^2260.0219^^ (#219) EMPLOYEE STATEMENT DELAYED
^OOPS(2260,D0,CA2F,D1,0)= (#.01) EMPLOYEE STATEMENT DELAYED [1W] ^
^OOPS(2260,D0,CA2G,0)=^2260.02^^ (#220) MEDICAL REPORT DELAYED
^OOPS(2260,D0,CA2G,D1,0)= (#.01) MEDICAL REPORT DELAYED [1W] ^
^OOPS(2260,D0,CA2H)= (#230) AGENCY NAME [1F] ^ (#231) AGENCY ADDRESS [2F] ^ (#232) AGENCY CITY [3F] ^ (#233) AGENCY STATE [4P:5]
==>^ (#234) AGENCY ZIP CODE [5F] ^ (#235) OWCP AGENCY CODE [6F] ^ (#236) OSHA SITE CODE [7F] ^ (#268)
==>SUPERVISOR TITLE [8F] ^ (#269) SUPERVISOR PHONE [9F] ^ (#269.1) SUPERVISOR PHONE EXT [10F] ^
^OOPS(2260,D0,CA2I)= (#237) EMPLOYEE DUTY STATION [1F] ^ (#238) DUTY STATION ADDRESS [2F] ^ (#239) DUTY STATION CITY [3F] ^
==>(#240) DUTY STATION STATE [4P:5] ^ (#241) DUTY STATION ZIP CODE [5F] ^ (#242) REGULAR HRS FROM TIME [6F] ^
==>(#243) REGULAR HRS TO TIME [7F] ^ (#244) REGULAR WORK SCHEDULE [8F] ^
^OOPS(2260,D0,CA2J)= (#245) NAME OF PHYSICIAN [1F] ^ (#246) PHYSICIAN ADDRESS [2F] ^ (#247) PHYSICIAN CITY [3F] ^ (#248)
==>PHYSICIAN STATE [4P:5] ^ (#249) PHYSICIAN ZIP CODE [5F] ^ (#250) FIRST DATE MEDICAL CARE [6D] ^ (#251)
==>DISABLED FOR WORK [7S] ^ (#252) DATE NOTICE RECEIVED [8D] ^ (#253) DATE/TIME WORK STOPPED [9D] ^ (#254)
==>DATE/TIME PAY STOPPED [10D] ^ (#255) DATE OF LAST EXPOSURE [11D] ^ (#256) DATE/TIME RETURNED TO WORK [12D] ^
==>(#270) PHYSICIAN TITLE [13P:2263.5] ^
^OOPS(2260,D0,CA2K,0)=^2260.0257^^ (#257) WORK DUTY CHANGED
^OOPS(2260,D0,CA2K,D1,0)= (#.01) WORK DUTY CHANGED [1W] ^
^OOPS(2260,D0,CA2L)= (#258) INJURY CAUSED BY 3RD PARTY [1S] ^ (#259) 3RD PARTY NAME [2F] ^ (#260) 3RD PARTY ADDRESS [3F] ^ (#261)
==>3RD PARTY CITY [4F] ^ (#262) 3RD PARTY STATE [5P:5] ^ (#263) 3RD PARTY ZIP CODE [6F] ^ (#264) SUPERVISOR
==>EXCEPTION [7F] ^
^OOPS(2260,D0,DUAL)= (#303) VETERAN [1S] ^ (#304) RECEIVE VETERAN BENEFITS [2S] ^ (#305) PENDING DISABILITY CLAIM [3S] ^ (#306)
==>VBA NUMBER [4F] ^ (#353) DUAL REFUSED [5S] ^ (#308) CONDITION ACCEPTED IN CLAIM [6F] ^ (#309) EMP NAME OF
==>DUAL BENEFIT [7P:200] ^ (#310) EMP DUAL BENEFITS E-SIGNATURE [8F] ^ (#311) EMP DUAL BENEFIT SIGN DATE [9D] ^
==>(#312) WC NAME FOR DUAL BENEFIT [10P:200] ^ (#313) WC DUAL BENEFITS E-SIGNATURE [11F] ^ (#314) WC DUAL
==>BENEFITS SIGN DATE [12D] ^
^OOPS(2260,D0,DUAL1)= (#307) MILITARY CLAIM BODY PARTS [1F] ^
^OOPS(2260,D0,OUTC,0)=^2260.095DA^^ (#95) INCIDENT OUTCOME
^OOPS(2260,D0,OUTC,D1,0)= (#.01) START DATE INCIDENT OUTCOME [1D] ^ (#1) END DATE INCIDENT OUTCOME [2D] ^ (#2) INCIDENT OUTCOME
==>[3S] ^ (#3) DAYS AWAY WORK [4N] ^ (#4) DAYS JOB TRANSFER/RESTRICTION [5N] ^ (#5) ESTIMATED RETURN DATE
==>[6D] ^ (#6) DATE OUTCOME CREATED [7D] ^ (#7) INCIDENT CREATED BY [8P:200] ^ (#8) LAST EDIT DATE [9D] ^
==>(#9) LAST EDITED BY [10P:200] ^ (#10) STATUS [11S] ^
^OOPS(2260,D0,WCES)= (#67) TRANSMIT TO WCMIS [1P:200] ^ (#68) WC ELECTRONIC SIGNATURE [2F] ^ (#69) WC DATE OF SIGNATURE [3D] ^
^OOPS(2260,D0,WCSE)= (#76) NAME OF SAFETY OFFICER [1P:200] ^ (#77) SAFETY OFFICER ELEC. SIGN [2F] ^ (#78) SAFETY OFF. ELEC. SIGN
==>DATE [3D] ^ (#79) EMPLOYEE HEALTH NAME [4P:200] ^ (#80) EMP HEALTH ELECT. SIGNATURE [5F] ^ (#81) EMP HEALTH
==>ELECT SIGN DATE [6D] ^
INPUT TEMPLATE(S):
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):