LA OWCA Second Injury Board Knowledge Questionnaire

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. 23:1021-1361.

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. 23:1208.1.
Employer*
Employee Name*
Date of Birth (mm/dd/yyyy)*

MonthDayYear
Date
Gender*

MaleFemale
Soc. Sec. # (last 4 digits only)*
Home Address
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Telephone Number*
Email*
Employee Signature*

Clear
Date*

MonthDayYear
Date
Employer Witness
Date

MonthDayYear
Date
Please place a check in the appropriate box next to each medical condition listed below. Each illness or condition requires a Yes (Y) or No (N) answer. For all conditions that you check yes, write a brief explanation on the Explanation Page.

Disease and Other Medical Conditions [Please check the appropriate box. Each illness/injury requires a Yes (Y) or No (N) answer.]
Diabetes*

YesNo
Silicosis*

YesNo
Varicose Veins*

YesNo
Asbestosis*

YesNo
Hyperinsulinism*

YesNo
Alzheimer’s*

YesNo
Emphysema*

YesNo
Hearing Loss*

YesNo
COPD*

YesNo
Hypertension*

YesNo
Head Injury*

YesNo
Epilepsy*

YesNo
Stroke*

YesNo
Cerebral Palsy*

YesNo
Tuberculosis*

YesNo
Multiple Sclerosis*

YesNo
Post Traumatic Stress*

YesNo
Osteomyelitis*

YesNo
Nervous Disorder*

YesNo
Muscular Dystropy*

YesNo
Migraine Headaches*

YesNo
Mental Retardation*

YesNo
Kidney Disorder*

YesNo
Loss of Use of Limb*

YesNo
Seizure Disorder*

YesNo
Sickle Cell Disease*

YesNo
Arthritis*

YesNo
Parkinson’s*

YesNo
Brain Damage*

YesNo
Asthma*

YesNo
Dementia*

YesNo
Thrombophlebitis*

YesNo
Arteriosclerosis*

YesNo
Hodgkin’s*

YesNo
Cancer*

YesNo
Double Vision*

YesNo
Mental Disorders *

YesNo
Hemophilia*

YesNo
Bleeding Disorder*

YesNo
Heart Disease/Heart Attack*

YesNo
Congestive Heart Failure*

YesNo
Vision Loss, one or both eyes*

YesNo
Disability from Polio*

YesNo
Psychoneurotic Disability*

YesNo
Ruptured or Herniated Disc*

YesNo
Ankylosis or Joint Stiffening*

YesNo
High/Low Blood Pressure*

YesNo
Carpal Tunnel Syndrome*

YesNo
Compressed Air Sequelae*

YesNo
Disease of the Lung*

YesNo
Coronary Artery Disease*

YesNo
Heavy Metal Poisoning*

YesNo
Surgical Treatment [Please check the appropriate box. Each illness/injury requires a Yes (Y) or No (N) answer.]
Spinal Disc Surgery*

YesNo
If Yes, What Year (approximate if unsure)
Spinal Fusion Surgery*

YesNo
If Yes, What Year (approximate if unsure)
Amputated Foot*

YesNoLeftRight
If Yes, What Year (approx. if unsure)
Amputated Leg*

YesNoLeftRight
If Yes, What Year (approx. if unsure)
Amputated Arm*

YesNoLeftRight
If Yes, What Year (approx. if unsure)
Amputated Hand*

YesNoLeftRight
If Yes, What Year (approx. if unsure)
Knee Replacement*

YesNoLeftRight
If Yes, What Year (approx. if unsure)
Hip Replacement*

YesNoLeftRight
If Yes, What Year (approx. if unsure)
Other Joint Replacement*

YesNo
If Yes, What Joint
If Yes, What Year
Other Surgical Procedure*

YesNo
If Yes, What Procedure
If Yes, What Year
Employee Signature*

Clear
Date*

MonthDayYear
Date
Employer Witness
Date

MonthDayYear
Date
EXPLANATION PAGE
Please use the space below to explain the illnesses and/or conditions that you checked a Yes (Y) or any other medical conditions that may not be listed on this form. Ask your employer for additional copies of this page if needed.
CONDITION 1
Year Diagnosed (approx)
Are you still treating for this condition?

YesNo
Are you taking medication for this condition?

YesNo
Do you have any permanent restrictions for this condition?

YesNo
Brief Explanation:
CONDITION 2
Year Diagnosed (approx)
Are you still treating for this condition?

YesNo
Are you taking medication for this condition?

YesNo
Do you have any permanent restrictions for this condition?

YesNo
Brief Explanation:
CONDITION 3
Year Diagnosed (approx)
Are you still treating for this condition?

YesNo
Are you taking medication for this condition?

YesNo
Do you have any permanent restrictions for this condition?

YesNo
Brief Explanation:
CONDITION 4
Year Diagnosed (approx)
Are you still treating for this condition?

YesNo
Are you taking medication for this condition?

YesNo
Do you have any permanent restrictions for this condition?

YesNo
Brief Explanation:
Employee Signature*

Clear
Date*

MonthDayYear
Date
Employer Witness
Date

MonthDayYear
Date
Please answer the following questions.
1. Has any doctor ever restricted your activities?*

YesNo
If “Yes,” please list the restrictions:
Were the restrictions:

PermanentTemporary
Are you currently restricted?

YesNo
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?*

YesNo
Please list the medical condition being treated:
Doctor’s Name:
Doctor’s 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 1
Prescribing Doctor
Medication 2
Prescribing Doctor
4. Have you ever had an on the job accident?*

YesNo
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?*

YesNo
If you answered YES, please provide:
Recommended surgery:
Approximate date of recommendation

MonthDayYear
Date
Doctor's Name:
Doctor's Specialty:
Doctor's Address:
Employee Signature:*

Clear
Date:*

MonthDayYear
Date
Employer Witness
Date

MonthDayYear
Date
WARNINGFAILURE 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. 23:1208.1.
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 Name:*
Employee Signature:*

Clear
Date:*

MonthDayYear
Date
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
Date

MonthDayYear
Date
Employer Witness Printed
Title
Should be Empty:

EXPLANATION PAGE

WARNINGFAILURE 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. 23:1208.1.