Determination of work-related injury

Applicant:________ Application time:________
Name of injured or occupational disease victim:______ Gender:___ ID No.:________     
Type of insurance: single work-related injury insurance for specific personnel
Insured unit:
Village committee and neighborhood committee (two types of village (community) committees):________
University under study (type of internship student):________               
Occupation/type of work/post of employees:________        
_____ Year___ Month___ Daily acceptance___ After the application for identification of work-related injury, the investigation and verification according to the submitted materials are as follows:
... (including accident time, place, injured process and verification, diagnosis time, injured part (name of occupational disease), basic information of medical treatment and diagnosis conclusion, etc.).
______ For accident injuries (or occupational diseases), refer to___ Article___ The provisions of the preceding paragraph fall within the scope of identification of work-related injuries, and are now recognized as work-related injuries (or deemed as such).
If you are not satisfied with this determination of work-related injury, you can apply for administrative reconsideration within 60 days from the date of receiving this decision, or file an administrative lawsuit with the people's court within 6 months.
(Special Seal for Occupational Injury Identification)
Date:
Note: This notice is in quadruplicate, with one copy kept by the social insurance administrative department, the injured workers or their close relatives, the insured unit and the social insurance agency respectively.