[Image ID: A blackout poem. The edges of the black are straight and rectilinear. I will indicate breaks in the line using the slash symbol /. Some of the excerpts include boxes where you could draw a check mark. I will indicate these by writing (box). The poem goes

Answer every question. / Please tell us if you want us to return them to you. / Select the heaviest weight lifted. / Using fingers to touch, / (Box) One hand (Box) Both hands / Using hands to seize, (Box) One hand (Box) Both hands / reduction / refusal / Termination / Penalty / You can give us more facts to add to your file. / You do not meet with the person who decides your case. / Notice of Decision — Unfavorable / Disabled worker’s name / Date given when disability began / Date of death. /end ID]