LA OWCA Second Injury Board Knowledge Questionnaire WARNING
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- Sabina McBride
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1 1001 North 23 rd Street Post Office Box Baton Rouge, LA (O) (F) Bobby Jindal, Governor Curt Eysink, Executive Director Office of Workers Compensation Administration Second Injury Board LA OWCA Second Injury Board Knowledge Questionnaire The following questionnaire should only be completed by individuals that have been hired for employment. Your employer may ask that you complete this questionnaire following your initial hire and periodically thereafter. The questionnaire may be used in the establishment of prior knowledge for the purpose of obtaining Second Injury Fund relief from the Second Injury Board. The Second Injury Board may reimburse your employer for workers compensation claims that meet certain criteria should you become injured on the job. This reimbursement in no way affects the benefits owed to you by your employer or their insurance company under the Louisiana Workers Compensation Act, La. R.S. 23: WARNING FAILURE TO ANSWER TRUTHFULLY AND/OR CORRECTLY TO ANY OF THE QUESTIONS ON THIS FORM MAY RESULT IN A FORFEITURE OF YOUR WORKERS COMPENSATION BENEFITS UNDER LA R.S. 23: Employer: Employee Name: Date of Birth: Male: Female: Soc. Sec. # (last 4 digits only): Home Address: Telephone Number: _( ) Equal Opportunity Employer/Program Auxiliary aids and services are available upon request to individuals with disabilities TDD#
2 Please place a check in the box next to medical conditions you currently have or have had previously. For all conditions that you check, write a brief explanation on the Explanation Page. No check mark in the box will indicate that you do not have nor have you ever had the corresponding condition. Disease and Other Medical Conditions Diabetes Cerebral Palsy Arthritis Heart Disease/Heart Attack Silicosis Tuberculosis Parkinson s Congestive Heart Failure Varicose Veins Multiple Sclerosis Brain Damage Vision Loss/one or both eyes Asbestosis Post Traumatic Stress Asthma Disability from Polio Hyperinsulinism Osteomyelitis Dementia Psychoneurotic Disability Alzheimer s Nervous Disorder Thrombophlebitis Ruptured or Herniated Disc Emphysema Muscular Distrophy Arteriosclerosis Ankylosis or Joint Stiffening Hearing Loss Migrane Headaches Hodgkin s High/Low Blood Pressure COPD Mental Retardation Cancer Carpal Tunnel Syndrome Hypertension Kidney Disorder Double Vision Compressed Air Sequelae Head Injury Loss of Use of Limb Mental Disorders Disease of the Lung Epilepsy Seizure Disorder Hemophilia Coronary Artery Disease Stroke Sickle Cell Disease Bleeding Disorder Heavy Metal Poisoning Surgical Treatment Spinal Disc Surgery Spinal Fusion Surgery Amputated foot Amputated leg Amputated arm Amputated hand Knee Replacement Hip Replacement Other Joint Replacement Year (approximate if unsure) Year (approximate if unsure) Joint Year Other Surgical Procedure Procedure Year
3 EXPLANATION PAGE Please use the space below to explain the conditions that you checked or any other medical conditions that may not be listed on this form. Ask your employer for additional copies of this page if needed.
4 Please answer the following questions. 1. Has any doctor ever restricted your activities? If Yes, please list the restrictions: Were the restrictions: Permanent Temporary Are you currently restricted? Yes No What is the medical condition for which you are restricted? 2. Are you presently treating with a doctor, chiropractor, psychiatrist, psychologist or other health care provider? Please list the medical condition being treated: Doctor s Name: Specialty: Doctor s Address: 3. If you are presently taking prescription medication other than those listed on the Explanation Page, please complete the requested information below. Medication: Prescribing Doctor: Medication: Prescribing Doctor: 4. Have you ever had an on the job accident? If you answered YES, please provide the date for each injury and the nature of the injury. How long were you on compensation? Name of Employer: 5. Has a doctor recommended a surgical procedure, which has not been completed prior to this date, including but not limited to knee, hip or shoulder replacement? If you answered YES, please provide: Recommended surgery Approximate date of recommendation: Doctor s Name: Specialty: Doctor s Address:
5 WARNING FAILURE TO ANSWER TRUTHFULLY AND/OR CORRECTLY TO ANY OF THE QUESTIONS ON THIS FORM MAY RESULT IN A FORFEITURE OF YOUR WORKERS COMPENSATION BENEFITS UNDER LA R.S. 23: I have completed this form honestly and to the best of my knowledge. I understand that providing false information or omitting pertinent information could result in loss of my workers compensation benefits should I become injured on the job. Employee Printed: I am an authorized representative of the employer designated to obtain and review the information provided by the employee on this questionnaire. I have confirmed that the employee understands the consequences associated with providing false information or omitting pertinent information. I have confirmed that the employee is able to read and understand the information provided on this questionnaire or I have personally read the questionnaire to the employee. I have provided the employee with as many copies of the Explanation Page as needed. I have confirmed the number of and labeled the pages of this questionnaire. Employer Witness Printed: Title:
LA OWCA Second Injury Board Knowledge Questionnaire WARNING
1001 North 23 rd Street Post Office Box 44187 Baton Rouge, LA 70804-4187 (O) 225-342-7866 800-201-2493 (F) 225-219-5968 Bobby Jindal, Governor Curt Eysink, Executive Director Office of Workers Compensation
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