Second Injury Questionnaire – Fill Out and Use

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.

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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	Y N
  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 Dystropy	  Arteriosclerosis	  Ankylosis or Joint Stiffening
  Hearing Loss	  Migraine 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 [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: _________________________
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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: _________________________

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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: _________________________
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