Second Injury Questionnaire – Fill Out and Use This PDF

The Second Injury Questionnaire is a method of identifying potential second injuries sustained by workers who have already been injured.

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Second Injury Questionnaire PDF Details

When you suffer an injury, there are a lot of steps that need to be taken in order to ensure that you get the best care possible. One of those steps may be filling out a second injury questionnaire form. This form is used to help calculate your workers' compensation benefits, so it's important that you fill it out correctly. In this blog post, we'll go over what information is required on the form and how to submit it.

Before you decide to fill in second injury questionnaire, you will need to understand more about the type of form you will use.

Question	Answer
Form Name	Second Injury Questionnaire
Form Length	6 pages
Fillable?	Yes
Fillable fields	178
Avg. time to fill out	37 min 10 sec
Other names	second injury questionnaire, amtrust second injury fund questionnaire, louisiana questionnaire, second injury fund questionnaire

12

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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louisiana questionnaire spaces to complete

Fill in the Year, approximate, if, unsure section with the details asked by the program.

Filling out louisiana questionnaire part 2

Put in writing any particulars you need within the area 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, and Year, approx, if, unsure

louisiana questionnaire Yearapproximateifunsure, SpinalFusionSurgery, Yearapproximateifunsure, AmputatedFootLeft, Right, Yearapproxifunsure, AmputatedLegLeft, Right, Yearapproxifunsure, AmputatedArmLeft, Right, Yearapproxifunsure, AmputatedHandLeft, Right, and Yearapproxifunsure fields to insert

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Filling out louisiana questionnaire step 4

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step 5 to completing louisiana questionnaire

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