ST-2

MEXICAN INSTITUTE OF SOCIAL SECURITY

BENEFITS MANAGEMENT DISCHARGE OPINION FOR
OCCUPATIONAL HEALTH COORDINATION
IMSS
DATA OF THE INSURED
1) PATERNAL AND MATERNAL SURNAME AND FIRST NAME 2) AFFILIATION NUMBER

3) CURP

4) REGISTRATION 5) BUDGET CODE OF UNIT D

COMPANY INFORMATION
6) NAME OR COMPANY NAME 7) REGI

9) DATE OF AC
OCCUPATIONAL HAZARD DATA OR CLAIM
8) TYPE OF RISK
DISEASE D
ACCIDENT OF ACCIDENT OF
WORK TRAYECTO 10) START OF
□OCCUPATIONAL DISEASE
PERMANENT DISABILITY YES n NO MARK
JUST FOR OCCUPATIONAL HEALTH
NOTE IN CASE OF SEQUELAE IN THE HEALTH SERVICE ON THE DATE OF COMMENCEMENT OF WORK.
PRIOR ASSESSMENT OF THE
11) LOCATION DELEGATION MEDICAL UNIT DAY MONTH YEAR

12) NAME OF THE PHYSICIAN WHO FORMULATED THIS REGISTRATION

OPINION
OCCUPATIONAL HEALTH SERVICE
 ST-2

OCCUPATIONAL HAZARD

ST-2

E ASCRIPSION

PATRONAL STRO

DAY MONTH YEAR

OF THE
E WORK

BORES DAY MONTH YEAR

THE WORK WILL BE DETERMINED BY THE CORRESPONDING SIGNATURE OF THE PHYSICIAN.