Washington > Workers Comp > Claims
Occupational Disease Work History F242-071-000 - Washington
| Occupational Disease Work History Form. This is a Washington form and can be used in Claims Workers Comp . |
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Department of Labor and Industries PO Box 44291 Olympia WA 98504-4291 Name OCCUPATIONAL DISEASE & EMPLOYMENT HISTORY Claim Number Occupational Disease Information Form This form must be completed if the claim isn't the result of a specific incident. An occupational disease is a condition caused by job duties or work conditions over a period of time. For allowance of an occupational disease claim, there must be: · Medical evidence supported by objective medical findings that the disease exists. · Medical opinion that the diagnosis is caused by work activities on a more probable than not basis. · Documentation that the disease was caused by work rather than conditions in everyday life or all employment in general. We require completion of this form to decide if the claim is allowable and to determine which job(s) contributed to the diagnosed condition. Instructions for Worker · · · · · Complete the Worker Information and the Employment History. Include all current and past employer(s). Provide as much detail as possible about your employer(s) and your job duties. Inaccurate or incomplete information may delay our decision. Failure to complete and submit this form may result in claim rejection. Worker Information What symptoms are you having? _______________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ When did you first notice these symptoms? ____/____/____ What were you doing when these symptoms began? __________________________________________________________ __________________________________________________________ __________________________________________________________ Has there been any recent change in your work duties that have affected your symptoms? YES NO If yes, please describe: _______________________________________ __________________________________________________________ Have you ever been seen by a provider for these symptoms in the past? YES NO If yes: Provider's name:_____________________________________ Date/Year Seen:_____________________________________ Provider's Address/City/State:__________________________ ___________________________ If yes, complete the attached medical records release form. Have you previously filed any claims for this condition? YES NO If yes, please list the states and claim numbers: State: __________________________ __________________________ __________________________ Claim Number: __________________________ __________________________ __________________________ Other Activities Complete the following for activities that you currently do or have done in the past. Sports type ____________________________ hrs per day: ____ days per wk: ____ Performed From: _____/_____/_____ To: _____/_____/_____ hrs per day: ____ days per wk: ____ Performed From: _____/_____/_____ To: _____/_____/_____ Musical Instruments type ________________ hrs per day: ____ days per wk: ____ Performed From: _____/_____/_____ To: _____/_____/_____ Woodworking/Construction/Painting/Gardening hrs per day:____ days per wk: ____ Performed From: _____/_____/_____ To: _____/_____/_____ Computers, Keyboarding, Gaming, hrs per day: ____ Text Messaging, etc. days per wk:____ Performed From: _____/_____/_____ To: _____/_____/_____ Auto/Engine Repair, Firearms, hrs per day: ____ Power Tools, etc. days per wk:____ Performed From: _____/_____/_____ To: _____/_____/_____ Sewing, Knitting, Crocheting, Crafts, etc. Other describe:_____________________________________________________________________________________ hrs per day: ____ Performed From: _____/_____/_____ To: _____/_____/_____ days per wk: ____ F242-071-000 occupational disease and work history 12-2010 -1- American LegalNet, Inc. www.FormsWorkFlow.com Name Claim Number For LNI use Employment History Include all employers. Copy this page if you need more space. Current or Last Employer: ____________________________________________ Job Title: _________________________________________________ Dates Employed: From ____/____/____ To ____/____/____ Phone Number: _______________________ Address:__________________________________________________ City/State: ________________________________________________ Was there a gap of more than two months between this job and your prior job? Yes No If yes, please briefly explain: ____________ _________________________________________________________ _________________________________________________________ _________________________________________________________ Check the specific job condition(s) you believe caused your symptoms: Job Duties Hrs per day Days per week Pushing/Pulling _________ _________ Use of Vibratory Tools _________ _________ Kneeling _________ _________ Overhead Work _________ _________ Pinching _________ _________ Keyboarding _________ _________ Lifting/Carrying _________ _________ Other Repetitive Tasks: _________ _________ ________________________________________________ Check the specific job condition(s) you believe caused your symptoms: Job Duties Hrs per day Days per week Pushing/Pulling _________ _________ Use of Vibratory Tools _________ _________ Kneeling _________ _________ Overhead Work _________ _________ Pinching _________ _________ Keyboarding _________ _________ Lifting/Carrying _________ _________ Other Repetitive Tasks: _________ _________ ________________________________________________ Check the specific job condition(s) you believe caused your symptoms: Job Duties Hrs per day Days per week Pushing/Pulling _________ _________ Use of Vibratory Tools _________ _________ Kneeling _________ _________ Overhead Work _________ _________ Pinching _________ _________ Keyboarding _________ _________ Lifting/Carrying _________ _________ Other Repetitive Tasks: _________ _________ ________________________________________________ Check the specific job condition(s) you believe caused your symptoms: Job Duties Hrs per day Days per week Pushing/Pulling _________ _________ Use of Vibratory Tools _________ _________ Kneeling _________ _________ Overhead Work _________ _________ Pinching _________ _________ Keyboarding _________ _________ Lifting/Carrying _________ _________ Other Repetitive Tasks: _________ _________ ________________________________________________ Prior Employer: __________
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