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STATE OF CALIFORNIA Division of Workers' Compensation Disability Evaluation Unit EMPLOYEE'S PERMANENT DISABILITY QUESTIONNAIRE This form will aid both the doctor and the Disability Evaluation Unit

How to fill out employee39s permanent disability questionnaire

To fill out the employee's permanent disability questionnaire, follow these steps:

1. Obtain the questionnaire form from the appropriate sources, such as the human resources department or the disability insurance provider.
2. Read the instructions carefully to understand the purpose and requirements of the questionnaire.
3. Provide accurate personal information, including the employee's name, contact details, and employee identification number.
4. Answer each question in the questionnaire honestly and to the best of your knowledge. If you are unsure about any question, consider seeking clarification from a supervisor or HR representative.
5. Provide comprehensive details about the employee's disability, including the onset date, diagnosis, and any medical treatment received.
6. If applicable, provide information about any accommodations or modifications made by the employer to facilitate the employee's work despite their disability.
7. Attach any supporting documents, such as medical records or reports, that may be requested by the questionnaire.
8. Review the completed questionnaire to ensure all questions have been answered accurately and all necessary information has been included.
9. Sign and date the questionnaire to certify its accuracy and completeness.
10. Submit the completed questionnaire to the designated recipient, following the instructions provided.

The employee's permanent disability questionnaire is typically required for individuals who have experienced a permanent disability and are seeking disability benefits or accommodations from their employer. This questionnaire helps assess the nature and extent of the disability, allowing the employer or insurance provider to determine appropriate support and benefits for the employee. It is usually needed when an employee is making a claim for long-term disability insurance or requesting workplace accommodations under disability laws. The exact requirements for obtaining and submitting the questionnaire may vary depending on the specific company or organization.

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