Second Injury Questionnaire PDF Details

The Second Injury Questionnaire serves as a critical tool within the Louisiana Workers’ Compensation framework, aimed at protecting employers while ensuring rights and benefits for employees with pre-existing medical conditions or disabilities. This form requires employees to disclose any such conditions, which might later qualify their employer for reimbursement from the Second Injury Board if an injury occurs on the job. The premise is based on promoting the hiring, retaining, or re-employment of individuals who, despite their disabilities, contribute valuably to the workforce. Completeness and honesty are paramount when filling out the questionnaire, as failing to provide accurate information can lead to the forfeiture of workers' compensation benefits. The form also includes provisions for maintaining the confidentiality of the medical information disclosed, emphasizing the importance of privacy. Moreover, it encompasses a broad range of health issues and surgical histories, highlighting the necessity for detailed medical disclosure. This comprehensive approach ensures that the Second Injury Board can accurately assess and process claims for reimbursement, thereby fostering a supportive employment environment for those with disabilities while mitigating potential financial risk for employers.

QuestionAnswer
Form NameSecond Injury Questionnaire
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesla owca second injury questionnaire, amtrust second injury fund questionnaire, la owca second injury board knowledge questionnaire, sib form

Form Preview Example

LOUISIANA WORKERS’ COMPENSATION SECOND INJURY BOARD

POST‐HIRE/CONDITIONAL JOB OFFER KNOWLEDGE QUESTIONNAIRE

EMPLOYEE: The intent of this questionnaire is to provide your employer with knowledge about any pre‐ existing medical condition or disability which may entitle your employer to reimbursement from the Louisiana Workers’ Compensation Second Injury Board in the event you suffer an on‐the‐job injury.1 This reimbursement in no way affects the benefits owed to you by your employer or its insurance company under the Louisiana Workers’ Compensation Act. La. R.S. 23:1021‐1361. However, your failure to answer truthfully and/or correctly to any of the question on this questionnaire may result in a forfeiture of your workers’ compensation benefits.

In order for your employer to be considered for reimbursement from the Second Injury Board, it has to show that it knowingly hired or retained you with a pre‐existing medical condition or disability. To establish its knowledge, your employer is requesting that this questionnaire be completed.

INSTRUCTIONS: Please answer ALL questions completely. If a response requires an explanation, please provide a brief description on the Explanation Page. If you have any questions or need help in answering the questions on this form, please ask for assistance from the Employer Representative signing this form.

NOTE: Since this questionnaire contains medical information, you can request that the form be kept CONFIDENTIAL and not made part of your personnel file. Please let your employer know that you want the completed questionnaire placed in a sealed folder for confidentiality purposes.

EMPLOYEE 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.

Employee Signature: _____________________________________________________

Date:

_____________

Employer Representative Signature: ________________________________________

Date:

_____________

Employer Name: ____________________________________________________________________________

Employee Name:____________________________________________________________________________

Date of Birth (mm/dd/yyyy): ____________

Male:

Female:

Soc. Sec. # (last 4 digits only): ____________

 

 

Home Address: _____________________________________________________________________________

Telephone Number: ( ____ ) __________________

1Under La. R.S. 23:1371(A), the purpose of the Second Injury Board is to encourage the employment, re‐ employment, or retention of employees who have a permanent partial disability.

PAGE 1 OF 6

SIB FORM D (10/17)

Disease and Other Medical Conditions you currently have or have ever had.

For all conditions that you check yes, write a brief explanation on the Explanation Page.

[Please check the appropriate box next to each. Every illness/injury requires a Yes (Y) or No (N) answer.]

Y N

Y N

Y N

  Diabetes

  Cerebral Palsy

  Arthritis

  Silicosis

  Tuberculosis

  Parkinson’s

  Varicose Veins

  Multiple Sclerosis

  Brain Damage

  Asbestosis

  Post Traumatic Stress

  Asthma

  Hyperinsulinism

  Osteomyelitis

  Dementia

  Alzheimer’s

  Nervous Disorder

  Thrombophlebitis

  Emphysema

  Muscular Dystrophy

  Arteriosclerosis

  Hearing Loss

  Migraine Headaches

  Hodgkin’s

  COPD

  Mental Retardation

  Cancer

  Hypertension

  Kidney Disorder

  Double Vision

  Head Injury

  Loss of Use of Limb

  Mental Disorders

  Epilepsy

  Seizure Disorder

  Hemophilia

  Stroke

  Sickle Cell Disease

  Bleeding Disorder

Y N

Heart Disease/Heart Attack

Congestive Heart Failure

Vision Loss, one or both eyes

Disability from Polio

Psychoneurotic Disability

Ruptured or Herniated Disc

Ankylosis or Joint Stiffening

High/Low Blood Pressure

Carpal Tunnel Syndrome

Compressed Air Sequelae

Disease of the Lung

Coronary Artery Disease

Heavy Metal Poisoning

Surgical Treatment [Please check the appropriate box. Each illness/injury requires a Yes (Y) or No (N) answer.] For each Yes (Y) answer, please complete the information corresponding to the surgery on the right. Additional information can be provided on the Explanation Page, if necessary.

Y N

 

 

 

Spinal Disc Surgery

Year (approximate if unsure)___________

Spinal Fusion Surgery

Year (approximate if unsure)___________

Amputated Foot

Left

Right

Year (approx. if unsure) ___________

Amputated Leg

Left

Right

Year (approx. if unsure) ___________

Amputated Arm

Left

Right

Year (approx. if unsure) ___________

Amputated Hand

Left

Right

Year (approx. if unsure) ___________

Knee Replacement

Left

Right

Year (approx. if unsure) ___________

Hip Replacement

Left

Right

Year (approx. if unsure) ___________

Other Joint Replacement

Joint ________________________ Year ________________

Other Surgical Procedure

Procedure ___________________ Year ________________

Other Surgical Procedure

Procedure ___________________ Year ________________

Other Surgical Procedure

Procedure ___________________ Year ________________

Other Surgical Procedure

Procedure ________

Year ________________

Employee Signature: ________________________________________

Date: _________________________

Employer Representative: ___________________________________

Date: _________________________

 

PAGE 2 OF 6

 

SIB FORM D (10/17)

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: ____________________________________________________ Year Diagnosed (approx):_______________

Are you still treating for this condition?

Yes

No

Are you taking medication for this condition?

Yes

No

Do you have any permanent restrictions for this condition?

Yes

No

Brief Explanation: ___________________________________________________________________________________

CONDITION: ____________________________________________________ Year Diagnosed (approx):_______________

Are you still treating for this condition?

Yes

No

Are you taking medication for this condition?

Yes

No

Do you have any permanent restrictions for this condition?

Yes

No

Brief Explanation: ___________________________________________________________________________________

CONDITION: ____________________________________________________ Year Diagnosed (approx):_______________

Are you still treating for this condition?

Yes

No

Are you taking medication for this condition?

Yes

No

Do you have any permanent restrictions for this condition?

Yes

No

Brief Explanation: ___________________________________________________________________________________

CONDITION: ____________________________________________________ Year Diagnosed (approx):_______________

Are you still treating for this condition?

Yes

No

Are you taking medication for this condition?

Yes

No

Do you have any permanent restrictions for this condition?

Yes

No

Brief Explanation: ___________________________________________________________________________________

Employee Signature: ________________________________________

Date: _________________________

Employer Representative: ___________________________________

Date: _________________________

PAGE 3 OF 6

SIB FORM D (10/17)

Please answer the following questions.

1. Has any doctor ever restricted your activities? Yes No

If “Yes,” please list the restrictions: __________________________________________________________

Were the restrictions: Permanent

Temporary

Are your activities currently restricted?

Yes

No

What is the medical condition for which you have restrictions? ____________________________________

2. Are you presently treating with a doctor, chiropractor, psychiatrist, psychologist or other health‐care

provider? Yes No

Please list the medical condition being treated: ________________________________________________

Doctor’s Name: ________________________________Specialty: __________________________________

Doctor’s Address: ________________________________________________________________________

3.If you are currently 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? Yes No

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? Yes No

If you answered YES, please provide:

Recommended surgery: _____________________________________

Approximate date of recommendation:_________________________

Doctor’s Name: ________________________________Specialty: __________________________________

Doctor’s Address: ________________________________________________________________________

Employee Signature: ________________________________________

Date: _________________________

Employer Representative: ___________________________________

Date: _________________________

 

PAGE 4 OF 6

 

SIB FORM D (10/17)

TO BE COMPLETED BY EMPLOYEE

EMPLOYEE WARNING

FAILURE TO ANSWER TRUTHFULLY AND/OR CORRECTLY TO ANY OF THE QUESTIONS ON THIS FORM MAY RESULT IN A FORFEITURE OF ANY AND ALL 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 Signature: _____________________________________________________ Date: _____________

Employee Printed Name: _____________________________________________________________________

PAGE 5 OF 6

SIB FORM D (10/17)

TO BE COMPLETED BY EMPLOYER REPRESENTATIVE

EMPLOYER WARNING

PURSUANT TO La. R.S. 23:1208 OF THE LOUISIANA WORKERS’ COMPENSATION ACT, IT SHALL BE UNLAWFUL FOR A PERSON, FOR THE PURPOSE OF OBTAINING OR DEFEATING ANY BENEFIT PAYMENT UNDER THE PROVISIONS OF THIS CHAPTER, EITHER FOR HIMSELF OR FOR ANY OTHER PERSON, TO WILLFULLY MAKE A FALSE STATEMENT OR REPRESENTATION. PENALTIES FOR VIOLATIONS INCLUDE IMPRISONMENT, FINES, AND/OR THE FORFEITURE OF BENEFITS.

You must certify the following:

1.That I am an authorized representative of the employer designated to obtain and review the information provided by the employee on this questionnaire;

2.That I have provided the employee with as many copies of the Explanation Page as needed and have confirmed the number of and labeled the pages of this questionnaire;

3.That I have provided assistance to the employee (if requested) in responding to the questions on this questionnaire;

4.That the information sought by this authorization is made on an applicant for employment only after a conditional job offer has been made and accepted, or on a current employee; and

5.That the information obtained in the authorization will NOT be used to discriminate in any manner against the individual who is the subject of this authorization on any basis, in violation of the Americans with Disabilities Act of 1990, 42 U.S.C. §12101, et seq., or any other state or federal law;

6.That if requested, a photocopy of this fully completed and signed form will be provided to the employee.

Employer Representative Signature:__________________________________________ Date: _____________

Employer Representative Printed Name: _________________________________________________________

Title: _____________________________________________________________________________________

PAGE 6 OF 6

SIB FORM D (10/17)

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Step 2: Now, you can start modifying the louisiana questionnaire. The multifunctional toolbar is at your disposal - insert, eliminate, transform, highlight, and perform many other commands with the words and phrases in the form.

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la owca second injury board knowledge questionaire spaces to complete

Fill in the Disease and Other Medical, Y N Cerebral Palsy, Y N Heart DiseaseHeart Attack, Y N Arthritis Parkinsons, Hodgkins Cancer Double, Surgical Treatment Please check, Y N Spinal Disc Surgery, Year approximate if unsure, Spinal Fusion Surgery, and Year approximate if unsure section with the details asked by the program.

Filling out la owca second injury board knowledge questionaire part 2

Put in writing any particulars you need within the area Spinal Fusion Surgery, Year approximate if unsure, Amputated Foot Left, Right, Year approx if unsure, Amputated Leg Left, Right, Year approx if unsure, Amputated Arm Left, Right, Year approx if unsure, Amputated Hand Left, Right, Year approx if unsure, and Knee Replacement.

la owca second injury board knowledge questionaire Spinal Fusion Surgery, Year approximate if unsure, Amputated Foot Left, Right, Year approx if unsure, Amputated Leg Left, Right, Year approx if unsure, Amputated Arm Left, Right, Year approx if unsure, Amputated Hand Left, Right, Year approx if unsure, and Knee Replacement fields to insert

The Employee Signature, Date, Employer Representative, Date, PAGE OF, and SIB FORM D area will be used to note the rights or obligations of both sides.

Filling out la owca second injury board knowledge questionaire step 4

Finish by reading the following fields and completing them as required: EXPLANATION PAGE Please use the, CONDITION Year Diagnosed approx, Are you still treating for this, Are you taking medication for this, Yes, Yes, Do you have any permanent, Yes, Brief Explanation, CONDITION Year Diagnosed approx, Are you still treating for this, Are you taking medication for this, Yes, Yes, and Do you have any permanent.

step 5 to completing la owca second injury board knowledge questionaire

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