• Second Injury 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 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.

  • FAILURE TO ANSWER TRUTHFULLY AND/OR CORRECTLY TO ANY OF THE QUESTIONS ON THIS FORM MAY RESULT IN A FORGEITURE OF YOUR WORKERS COMPENSATION BENEFITS UNDER LA R.S. 23:1208.1.

  • DATE OF BIRTH:*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -
  • Image field 170

  • Please place a check in the appropriate box next to each medical condition listed below. Each illness or condition requires a YES (Y) or a NO (N) answer. For all conditions that you check yes, write a brief explanation on the Explanation Page.
  • Diabetes*
  • Silicosis*
  • Vericose Veins*
  • Asbestosis*
  • Hyperinsulinism*
  • Alzheimer's*
  • Emphysema*
  • Hearing Loss*
  • COPD*
  • Hypertension*
  • Head Injury*
  • Epilepsy*
  • Stroke*
  • Cerbral 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*
  • Arthritis*
  • Parkinson's*
  • Brain Damage*
  • Asthma*
  • Dementia*
  • Thrombophlebitis*
  • Arteriosclerosis*
  • Hodgkin's*
  • Cancer*
  • Double Vision*
  • Mental Disorder*
  • Hemophilia*
  • Bleeding Disorder*
  • CHF*
  • Vision Loss, One or Both eyes*
  • Heart Disease/Heart Attack*
  • Disability from Polio*
  • Psychoneurotic Disability*
  • Ruptured or Herniated Disc*
  • Ankylosis or Joint Stiffness*
  • High / Low Blood pressure*
  • Carpal Tunnel Syndrome*
  • Compressed Air Sequelae*
  • Disease of the Lung*
  • Coronary Artery Disease*
  • Heavy Metal Poisoning*
  • Spinal Disc*
  • Approximate Date of Procedure
     - -
    2 digit month, 2 digit day, 4 digit year
  • Spinal Fusion*
  • Approximate Date of Procedure
     - -
    2 digit month, 2 digit day, 4 digit year
  • Amputated Foot*
  • Location
  • Approximate Date of Procedure
     - -
    2 digit month, 2 digit day, 4 digit year
  • Amputated Leg*
  • Location
  • Approximate Date of Procedure
     - -
    2 digit month, 2 digit day, 4 digit year
  • Amputated Arm*
  • Location
  • Approximate Date of Procedure
     - -
    2 digit month, 2 digit day, 4 digit year
  • Amputated Hand*
  • Location
  • Approximate Date of Procedure
     - -
    2 digit month, 2 digit day, 4 digit year
  • Knee Replacement*
  • Location
  • Approximate Date of Procedure
     - -
    2 digit month, 2 digit day, 4 digit year
  • Hip Replacement*
  • Location
  • Approximate Date of Procedure
     - -
    2 digit month, 2 digit day, 4 digit year
  • Other Joint Replacement*
  • Location
  • Approximate Date of Procedure
     - -
    2 digit month, 2 digit day, 4 digit year
  • Other Surgical Procedures*
  • Approximate Date of Procedure
     - -
    2 digit month, 2 digit day, 4 digit year

  • EXPLANATION PAGE

    Please use the space below to explain the illness and/or condition that you checked a Yes (Y) or any other medical conditions that may not be listed on this form.
  • Approx Date Diagnosed with condition:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you still treating this condition?*
  • Are you taking medications for this condition?*
  • Do you have any permanent restrictions for this condition?*
  • Approx Date Diagnosed:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you still treating this condition?*
  • Are you taking medications for this condition?*
  • Do you have any permanent restrictions for this condition?*
  • Approx Date Diagnosed:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you still treating this condition?*
  • Are you taking medications for this condition?*
  • Do you have any permanent restrictions for this condition?*
  • Approx Date Diagnosed:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you still treating this condition?*
  • Are you taking medications for this condition?*
  • Do you have any permanent restrictions for this condition?*

  • Please answer the following questions:
  • Has any doctor ever restricted your activities?*
  • Were the restrictions permanent or temporary?*
  • Are you currently restricted?*
  • Are you presently treating with a doctor, chiropractor, psychiatrist, psychologist or other healthcare provider?*
  • Have you ever had an on the job accident?
  • Has a doctor ever recommended a surgical procedure, which has not been completed prior to this date, including but not limited to knee, hip, or shoulder replacement?

  • 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.

  • TODAY'S DATE
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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, etseq., 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.

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