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The image displays a document with a header that reads "Bureau of Indian Affairs," followed by the subheading "Health Services." The document appears to be an official form or report related to the health services provided by the Bureau of Indian Affairs. It includes sections for "Date," "Injury/Illness Description," and other details such as "Time Injured," "Cause," and a section titled "Work Status After." There is also a table with columns labeled "Body Part Injured," "Type of Injury or Illness," and "Details." The form seems to be used for recording workplace injuries or illnesses within the context of the Bureau's health services.