EMPLOYEE'S NOTICE OF INJURY OR OCCUPATIONAL DISEASE FOR FRANK R. OLSON

• Document Type: SPECIALCOLLECTION
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): 00144964
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 1
• Document Creation Date: November 22, 2024
• Document Release Date: January 15, 1983
• Publication Date: November 27, 1953

S.
EMPLOYEE'S NOTICE OF INJURY OR OCCUPATIONAL DISEASE
Federal Fmployece Compensation Act
Thix notice shonhl stihmitted to the immediate superior by an injured civil employee of the rederal Government.
Or by someone on hi: h�bf.ff. utiLin IN blurs atter the injury. Nntice t:tny be ei.en either persnaally or by mail. It
be retained by the iwcrior ti�le.� the injury eati�vs di ;ability fiu� %cork tn�yrinii (hr day or shift when iniure ocratteci.
Or rectilic in any ch:tr�zo.� n�.::::n-t the 1:a:rt3U for medical eNuen,e. %km he fora ardeil In Ike L. s�
OF I..11:01:. iturran It; Compriu.ation. tn.:ether %silt the t. :icial superior's rvpurt of injury, Form C. A.2. ;:rrisre
Compensation is paid. written cl.tini on Form C. A. 4 tnu.t he submitted tu the liureau.
�
I. I hereby certify that I rim employed as a
. � Date of this notice
2"7 2Tovber
� St3C07."V;t5 07.1
(Occupation,
at the . T�71:;'="Zslt;11':5
(Pure or cron:�4-nent)
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and on -27- AID*
(Liss of %irk, 1Da?..), � (Hour. a. m..or p. Iii.)
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I was injured in the performance of my duties at t ".
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(Locatn lubere ;ism, accort�det
in
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Cause of injury .
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(1,22. rriLvas Lest )uu can new and�uhy injury occurred)
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NatUre of injury_ .....
.j Warne part �iterte.J.-trattured telt Ire, bruist�Tri.:ht
. Names of witnesses to iiijury
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. If this notice was not given within;IS hours.after..the injury, explain reason for delay and state name
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of person to whom notice was first given, and when -:.--4-1\11' Yu! L.%-t-c-'''. :'� :- tk ��/-1.�
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. This injury was not caused by my willful misconduct, intention to bring- about the injury or death of
yself or of another.' nor by my intoxication, and I hereby make claim fur. compensation Ind medical
eatment to which I may be entitled by reason of the injury sustained by me.
C. A. II
�i.'1Oto�ct :3.134
S.. ee.e.������ �42.22.611�2�Kt 3114.14911�9
Nam c _t kY � er.LCI. V. 1.1 .1: Lutes
n":".:1I- F., Cl-on
Address ........... ic;:.
(Street and number)
'd �
(City or loon) (Stott)
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