Massachusetts > Workers Comp
Employees Hearing Memorandum 161 - Massachusetts
| Employees Hearing Memorandum Form. This is a Massachusetts form and can be used in Workers Comp . |
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The Commonwealth of Massachusetts FORM 161 Department of Industrial Accidents 600 Washington Street 7th Floor, Boston, Massachusetts 02111 Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470 http://www.mass.gov/dia Page 1 of 2 EMPLOYEES HEARING MEMORANDUM TO BE COMPLETED BY COUNSEL FOR THE EMPLOYEE PRIOR TO HEARING DATE: _____________________________________ EMPLOYEE: _____________________________________ COUNSEL FOR EMPLOYEE: _____________________________________ ADDRESS: _____________________________________ _____________________________________ DATE OF INJURY: _____________________________________ CLAIMS: 1. Section 34 from ___________________ to _______________________ 2. Section 35 from ___________________ to _______________________ 3. Section 36 from ___________________ to _______________________ 4. Section 13 and 30 in the amount of $____________________________ 5. Section 31 from ___________________ to _______________________ or in the amount of $_________________________________________ 6. Section 28 from __________________ to ________________________ or in the amount of $_________________________________________ 7. Other: ____________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Request Permission to Depose: Dr. ________________________________________________________ ________________________________________________________ (over) Form 161 - Revised 8/2004 - Reproduce as needed.<<<<<<<<<********>>>>>>>>>>>>> 2 Page 2 of 2 ISSUES TO BE ADDRESSED AT HEARING: a. Stipulations of Fact: _________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ b. Witnesses at Hearing: 1. _________________________________________________ 2. _________________________________________________ 3. _________________________________________________ 4. _________________________________________________ 5. _________________________________________________ c. Exhibits to be Marked at Hearing: 1. _________________________________________________ 2. _________________________________________________ 3. _________________________________________________ 4. _________________________________________________ 5. _________________________________________________ d. Medical Reports [Under 452 CMR 1.11 (6)]: 1. _________________________________________________ 2. _________________________________________________ 3. _________________________________________________ 4. _________________________________________________ 5. _________________________________________________ Medical Reports must be accompanied by the physicians curriculum vitae or stipulation of qualifications. Will an Interpreter be Needed?: Language to be Interpreted (if applicable): YES NO NOTE :The party offering testimony by a witness who requires an interpreter must provide a certified interpreter at the time of hearing.
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