Second Injury Board Post-Hire Conditional Job Offer Knowledge Questionnaire {SIB FORM D}

1001 North 23rd Street Post Office Box 44187 Baton Rouge, LA 70804-4187 (O) (F) 225-342-7866 800-201-2493 225-219-5968 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. 23:1021 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): ____________ Soc. Sec. # (last 4 digits only): ____________ Home Address: _____________________________________________________________________________ Telephone Number: ( ____ ) __________________ Employee Signature: ________________________________________ Employer Witness: _________________________________________ Date: _________________________ Date: _________________________ Male: Female: PAGE _____ OF______ SIB FORM D 12/10 | Equal Opportunity Employer/Program | www.laworks.net Auxiliary aids and services are available upon request to individuals with disabilities · TDD# 800-259-5154 | American LegalNet, Inc. www.FormsWorkFlow.com 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 YN [Please check the appropriate box. Each illness/injury requires a Yes (Y) or No (N) answer.] YN Diabetes Silicosis Varicose Veins Asbestosis Hyperinsulinism Alzheimer's Emphysema Hearing Loss COPD Hypertention Head Injury Epilepsy Stroke YN Cerebral Palsy Tuberculosis Multiple Sclerosis Post Traumatic Stress Osteomyelitis Nervous Disorder Muscular Dystropy Migraine Headaches Mental Retardation Kidney Disorder Loss of Use of Limb Seizure Disorder Sickle Cell Disease YN Arthritis Parkinson's Brain Damage Asthma Dementia Thrombophlebitis Arteriosclerosis Hodgkin's Cancer Double Vision Mental Disorders Hemophilia Bleeding Disorder 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 YN [Please check the appropriate box. Each illness/injury requires a Yes (Y) or No (N) answer.] Spinal Disc Surgery Spinal Fusion Surgery Amputated Foot Amputated Leg Amputated Arm Amputated Hand Knee Replacement Hip Replacement Other Joint Replacement Other Surgical Procedure Year (approximate if unsure)___________ Year (approximate if unsure)___________ Left Left Left Left Left Left Right Right Right Right Right Right Year (approx. if unsure) ___________ Year (approx. if unsure) ___________ Year (approx. if unsure) ___________ Year (approx. if unsure) ___________ Year (approx. if unsure) ___________ Year (approx. if unsure) ___________ Joint ________________________ Year ________________ Procedure ___________________ Year ________________ Employee Signature: ________________________________________ Employer Witness: _________________________________________ Date: _________________________ Date: _________________________ PAGE _____ OF______ SIB FORM D 12/10 American LegalNet, Inc. www.FormsWorkFlow.com 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? Are you taking medication for this condition? Do you have any permanent restrictions for this condition? Yes Yes Yes No No No Brief Explanation: ___________________________________________________________________________________ CONDITION: ____________________________________________________ Year Diagnosed (approx):_______________ Are you still treating for this condition? Are you taking medication for this condition? Do you have any permanent restrictions for this condition? Yes Yes Yes No No No Brief Explanation: ___________________________________________________________________________________ CONDITION: ____________________________________________________ Year Diagnosed (approx):_______________ Are you still treating for this condition? Are you taking medication for this condition? Do you have any permanent restrictions for this condition? Yes Yes Yes No No No Brief Explanation: ___________________________________________________________________________________ CONDITION: ____________________________________________________ Year Diagnosed (approx):_______________ Are you still treating for this condition? Are you taking medication for this condition? Do you have any permanent restrictions for this condition? Yes Yes Yes No No No Brief Explanation: ___________________________________________________________________________________ Employee Signature: ________________________________________ Employer Witness: _________________________________________ Date: _________________________ Date: _________________________ PAGE _____ OF______ SIB FORM D 12/10 American LegalNet, Inc. www.FormsWorkFlow.com Please answer the following questions. 1. Has any doctor ever restricted your activities? Yes No If "Yes," please list the restrictions: ______________________________