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Employees Disability Questionnaire DEU 100 - California
| Employees Disability Questionnaire Form. This is a California form and can be used in EDD Forms Workers Comp . |
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STATE OF CALIFORNIA Division of Workers' Compensation Disability Evaluation Unit EMPLOYEE'S DISABILITY QUESTIONNAIRE This form will aid the doctor in determining your permanent impairment or disability. Please complete this form and give it to the physician who will be performing the evaluation. The doctor will include this form with his or her report and submit it to the Disability Evaluation Unit, with a copy to you and your claims administrator. Employee Social Security No. Street and Number City, State, Zip Code Date of Injury Claim number Date of Birth Employer Nature of employer's business PLEASE ANSWER THE FOLLOWING QUESTIONS FULLY, using reverse side if needed: How was your evaluating doctor selected? (check one) From a list of doctors provided by the State of California, Division of Workers' Compensation. Other (explain) What is the name of the doctor who will be doing the evaluation? When is your examination scheduled? What were your job duties at the time of your injury? What is the disability resulting from your injury? How does this injury affect you in your work? Have you ever had a disability as a result of another injury or illness? Please describe the disability? If so, when? Sign here __________________________________________Date: _______________________________ DEU Form 100 (Rev. 06-05) American LegalNet, Inc. www.USCourtForms.com
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