This government document is issued by Department of Industrial Accidents (DIA) for use in Massachusetts
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https://www.mass.gov/doc/c-l-294-updated-forms-and-requirements-for-ss-3737a-claims/download?_ga=2.213392660.1854129817.1751542062-2000327536.1747311789&_gl=1*dwr4pq*_ga*MjAwMDMyNzUzNi4xNzQ3MzExNzg5*_ga_MCLPEGW7WM*czE3NTE1NDIwNjIkbzY4JGcxJHQxNzUxNTQzODI1JGo2MCRsMCRoMA..