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WORKER IS COMPENSATION INJURY QUESTIONNAIRE Please Print: Name: Today's Date: Employer's Business Name at time of Accident: Employer's Phone: Employer's Address Occupation: Yes No Previous Workers

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How to fill out workers compensation injury questionnaire

01

Start by obtaining a copy of the workers compensation injury questionnaire.

02

Review the questionnaire to understand the information and sections it requires.

03

Begin by filling out your personal details accurately, such as your name, address, and contact information.

04

Provide an accurate account of how the injury occurred, including the date, time, and location.

05

Describe the nature of the injury in detail, including the body parts affected and the intensity of the pain or discomfort.

06

When discussing the cause of the injury, provide a clear explanation of the circumstances leading up to it.

07

Include any witnesses to the incident, if available, along with their contact information.

08

List any medical professionals or facilities you have consulted or are currently being treated by.

09

Attach any relevant medical reports, test results, or imaging studies related to your injury.

10

Sign and date the questionnaire, ensuring all information provided is accurate and truthful.

Who needs workers compensation injury questionnaire?

01

Employees who have suffered a work-related injury or illness and intend to file a workers compensation claim.

02

Employers who need to provide the questionnaire to their injured employees for claims processing.

03

Healthcare professionals who are involved in diagnosing and treating work-related injuries and need to gather necessary information.

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