WORKERS’ COMPENSATION INVESTIGATION STATEMENT/INTERVIEW GUIDE
· ASK THE CLAIMANT IF HE/SHE IS REPRESENTED PRIOR TO ASKING ANY QUESTIONS.
· REQUEST ALL RELEASES TO BE SIGNED PRIOR TO STARTING INTERVIEW.
· AUDIO RECORD THE INTERVIEW.
DATE ______TIME ______PERMISSION___NAME______
MAIDEN/MARRIED ______AGE____DIV______HGT ____ WGT______
SSN______PHONE ______RIGHT/LEFT HANDED______
CURRENT ADDRESS ______
LENGTH AT ADDRESS ______M-S-W-D ….DEPENDENTS______
DIVORCE DATE/COUNTY/STATE ______
PRIOR ADDRESS ______
PRIOR EMPLOYERS (PAST TWO YEARS)
NAME ______CITY/STATE ______INJURIES ______
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NAME______CITY/STATE______INJURIES______
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IF CLAIM, TYPE & DRS/HOSP ______
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CURRENT EMPLOYER______DATE HIRED ______JOB TITLE ______SUPV. ______JOB DUTIES ______
WAGES _____PER ______SHIFT HOURS ______HOURS PER WEEK______
DAYS WORKED EACH WEEK ______
CO-WORKERS NAMES ______
CONCURRENT EMPLOYMENT ______
ADDRESS/PHONE______
SUPV______DUTIES______
DAYS WORKED EACH WEEK ______
ANY INJURIES______INJURY DATE(S)______
INJURY TYPE______HOSPITAL______
DRS.______
PERMANENT DISABILITY ______
PERMANENT RESTRICTIONS______
INSURER______CLAIM STATUS______
SELF EMPLOYMENT ______COMPANY NAME______
ADDRESS ______
JOB DESCRIPTION/DUTIES______
INCOME PER WEEK______INJURIES______
HOSPITAL/CLINIC/DRS______
DISABILITY/RESTRICTIONS______
INSURER ______CLAIM STATUS______
FAMILY DR/CLINIC ______
ADDRESS ______PHONE______
DATE OF INJURY ______TIME______SPECIFIC LOCATION ______
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WHAT HAPPENED______
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WITNESS ______
WITNESS LOCATION IN RELATION TO YOU ______
SPECIFIC INJURY(S)______
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LOCATION/TYPE PAIN______
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WHO REPORTED TO______DATE/TIME______
WHO ELSE DID YOU TELL______
DID YOU GIVE THEM THE SAME INCIDENT/INJURY DESCRIPTION YOU JUST GAVE ME ______IF DELAY, WHY ______
WHAT PHYSICAL SYMPTOMS (FACIAL EXPRESSIONS OF PAIN, LIMPING, WALKING BENT OVER, ETC.) WOULD CO-WORKERS HAVE NOTED AFTER THE INCIDENT ______
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LOCATION OF FIRST TREATMENT ______
DOCTOR ______TYPE TREATMENT______
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DESCRIBE FOLLOW-UP CARE RECEIVED______
NAMES OF OTHER TREATING DRS.______
PHYSICAL THERAPY ______SCHEDULED DAYS ______
DATE OF NEXT DOCTOR VISIT______CURRENT RESTRICTIONS ______
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WHAT ARE YOU UNABLE TO DO NOW COMPARED TO BEFORE______
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DAYS MISSED SINCE INCIDENT ______ANTICIPATED RTW DATE______
HAS DOCTOR RECOMMENDED RTW LT. DUTY ______
DATE RETURNED ______
SAME INJURY (AS THIS CLAIM) BEFORE ______DATE______LOCATION OF
INJURY______WHAT HAPPENED ______
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______TREATING HOSPITALS/DRS/CHIROS______
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INSURER ______CLAIM STATUS______
PERMANENT RESTRICTIONS______
PRIOR W/C CLAIMS BEFORE ______DATE(S)______
EMPLOYER(S) ______
ADDRESS______
TYPE INJURY______
TREATING HOSPITAL/DRS/CHIROS______
INSURER ______CLAIM STATUS______
PERMANENT RESTRICTIONS______
NOTES ______
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ANY TYPE OF INJURY CLAIMS BEFORE ______
DATE______TYPE CLAIM ______
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INCIDENT LOCATION______
POLICE DEPT. INVOLVED______NAMES OF OTHER PARTIES______
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TYPE INJURY______
TREATING HOSPITAL/DRS/CHIROS______
INSURER______CLAIM STATUS______
PERMANENT RESTRICTIONS______
PRIOR S/F, AUTO, MC, PRODUCT______DATE______
LOCATION______DR/HOSP______
ANY HOME INJURIES______
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OTHER THAN ABOVE, NAMES OF ALL DRS/HOSPITALS/CLINICS/CHIROS SEEN IN PAST THREE YEARS______
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ALCOHOL/DRUGS/MEDICATIONS USED AT TIME OF LOSS______
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ANY PRE-EXISTING DISABILITIES______
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PHYSICAL ACTIVITIES YOU PARTICIPATED IN PRIOR TO D/L______
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HOW ARE YOU CURRENTLY PASSING TIME______
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CAN YOU THINK OF ANY OTHER CAUSE FOR YOUR CURRENT INJURY(S)______
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(SUBRO) IF EQUIPMENT MALFUNCTION CAUSED INJURY, DESCRIBE THE MALFUNCTION ______
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TYPE EQUIPMENT______MAKE______
MODEL______WHO MAINTAINS______
AGE OF MACHINE ______
HEALTH INSURANCE______PROVIDER______
CLAIM ADDRESS/PHONE______
GROUP/I.D. NUMBER(S)______
CIVIL/CRIM HX______
ADD’L NOTES/SPECIFIC QUESTIONS______
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DEFENSES: WORK RELATED? SPECIFIC INCIDENT? HORSEPLAY? DEVIATION WHILE TRAVELING? ACTIVELY TREATING PRE-EXISTING CONDITION? INTENTIONAL ACT? INTERVENING ACCIDENT? DISCREPANCIES? SUBROGATION? OBVIOUS INTOXICATION?