North Dakota > Workers Comp
Repetitive Motion Questionnaire SFN 50306 - North Dakota
| Repetitive Motion Questionnaire Form. This is a North Dakota form and can be used in Workers Comp . |
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REPETITIVE MOTION QUESTIONNAIRE CLAIMS DIVISION SFN 50306 (05/2008) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com Injured Worker's Name Claim Number PAGE 1 Body Part Mailing Date DIRECTIONS: PLEASE PRINT OR TYPE USING BLACK OR BLUE INK. Read and answer each question. If additional space is needed to respond, use the back of these pages or a separate sheet of paper. Please be sure to sign and date the last page and return this questionnaire to Workforce Safety & Insurance at the address listed above within 14 days from the mailing date listed above. Injured workers are subject to penalty for failure to comply or for any false statement. 1. a. Describe, as best you can, the motion/movements of your shoulder (s), arm(s), wrist(s), hand(s), and elbow(s) required by your job (including computer usage). b. How many hours/minutes per day/week do you spend performing the described movements? c. How long have you worked for your present employer? d. If employed with this employer less than one year, please list previous employer(s), how long employed with the previous employer(s), and a description of the job(s) performed at the previous employer(s). e. f. No Yes Do you operate any vibrating machinery? Have you always done this type of work (the current duties outlined in question 1a) for your employer? No Yes If you moved from another position in the company, please provide the details of the prior job, how long you were in the prior job, and when you moved to your current job. 2. a. b. No Yes Do you work more than one job or own a home-based business? If yes, please complete the following for each job. What is the name, address, and phone number of your employer? How long have you worked there? c. Please describe your work duties. d. Do you farm / ranch? Yes No C63 American LegalNet, Inc. www.FormsWorkFlow.com REPETITIVE MOTION QUESTIONNAIRE (con't) Claim Number Injured Worker PAGE 2 OF 4 3. a. b. Have you ever injured (i.e. fractured, sprained) your shoulder(s), arm(s), wrist(s), hand(s), or elbow(s) No Yes before? If yes, how many times? c. If yes, where did the injury occur? d. If yes, how did the injury occur? e. Explain, on a separate sheet if needed, any other details related to prior shoulder, arm, wrist, hand or elbow injuries. f. Have you ever treated previous symptoms on your own, such as using a brace, exercises, over the counter No Yes medications, etc? If yes, please explain . 4. a. b. Have you had any Electromyography (EMG)/Nerve Conduction tests? If yes, please list dates and results: Yes No 5. a. Do you experience any pain when bending your hand(s) forward? If yes, please explain: Yes No b. Do you experience any pain when bending your hand(s) backward? If yes, please explain: Yes No 6. a. Have you ever had x-rays taken for any reason on your shoulder(s), arm(s), wrist(s), hand(s) or elbow(s)? No Yes If yes, please explain: b Do you know of any x-ray findings that show a fracture in your shoulder(s), arm(s), wrist(s), hand(s) or No Yes elbow(s)? If yes, please explain: c. Do you know of any x-ray findings that show arthritis in your shoulder(s), arm(s), wrist(s), hand(s) or No Yes elbow(s)? If yes, please explain: C63 American LegalNet, Inc. www.FormsWorkFlow.com REPETITIVE MOTION QUESTIONNAIRE (con't) Claim Number Injured Worker PAGE 3 OF 4 7. a. What is your dominant hand? Right Left 8. a. Have you had or do you have any hobbies, i.e. knitting, crocheting, cross-stitching, gardening, canning, No Yes piano? If yes, describe them and state how often you do them. b. How many hours a day do you play video or computer games? c. How many hours a day do you use your home computer? 9. a. Have you or do you participate in any sports, i.e. fishing, bowling, weightlifting, darts? If yes, describe the sport and how often you participate. Yes No b. Yes Do you participate in a regular exercise program? If yes, please explain the activity and frequency of the exercise. No 10. a. Have you ever been diagnosed as having, or maybe having, diabetes, kidney disease, liver disorder, No If yes, explain: Yes thyroid disease, or alcoholism? b. Please provide the names and addresses of all medical doctors or other health care professionals who have treated you for this condition. (Continue on back if needed.) Address Complete Name City, State, Zip Phone Time Frame No Yes Have you ever had any neck problems or injuries? If yes, please list any medical doctor, chiropractor, physical therapist, occupational therapist, or other health care professional that you treated with for your neck problems or injuries. (Continue on back if needed.) Time Frame Phone City, State, Zip Address Complete Name 11. 12. a. Yes Have you ever been involved in an automobile accident? If yes, what body part was injured and when did the accident occur? No b. Did you need to seek medical treatment for the auto accident? Yes No C63 American LegalNet, Inc. www.FormsWorkFlow.com REPETITIVE MOTION QUESTIONNAIRE (con't) Claim Number Injured Worker PAGE 4 OF 4 13. a. b. Have you ever been told that the pain in your shoulder(s), arm(s), wrist(s), hand(s) or elbow(s) is related to No Yes your work duties? If yes, what is the name of the physician who told you that your problem(s) was/were related to your work duties? c. What was the approximate date the physician told you? 14. a. Please provide any other information that may be helpful in determining the cause or extent of your pain or injury. 15. a. b. c. d. Women: Have you had any post menopausal symptoms or gynecological abnormalities? No Yes No Yes Have you taken oral contraceptives or similar hormones? No Yes Are you or have you been pregnant? If yes to question 15c, how long ago was your last pregnancy? 16. a. b. No Yes Have you had shoulder, arm, wrist, and/or elbow surgery(s)? If yes, what body part(s) (specify right or left)? When did you have the surgery? At what medical facility? c. If no, when do you expect to have surgery? At what medical facility? UPON COMPLETION OF THIS FORM, PLEASE SIGN, DATE, AND RETURN IT TO: Attn: Claims Department Workforce Safety & Insurance PO Box 5585 Bismarck, ND 58506-5585 Fraud Warning for Filing False Claims Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the receipt of i
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