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Kaiser On-the-Job MR INITIAL INDUSTRIAL VISIT QUESTIONNAIRE Name To be completed by the injured worker at the initial visit for an industrial injury or illness PLEASE PRINT LAST NAME IMPRINT AREA YOUR INFORMATION SEX M F FIRST NAME HOME ADDRESS HOME PHONE BIRTH DATE SOCIAL SECURITY CITY STATE ZIP OTHER PHONE WORK PHONE JOB TITLE OR DESCRIBE THE TYPE OF WORK YOU DO ARE YOU A LONGSHOREMAN Yes No EMPLOYER INFORMATION COMPANY NAME SUPERVISOR/CONTACT ADDRESS ABOUT YOUR INJURY OR ILLNESS WHERE WERE YOU WHEN YOU BECAME INJURED OR ILL LOCATION IF DIFFERENT FROM YOUR EMPLOYER S ADDRESS AM PM DATE YOU WERE INJURED OR BECAME ILL TIME HAVE YOU REPORTED THIS AT WORK ALL INJURED WORKERS MUST COMPLETE THE EMPLOYEE S CLAIM FOR WORKERS COMPENSATION BENEFITS FORM DWC-1. HAVE YOU COMPLETED AND RETURNED THE FORM TO YOUR EMPLOYER HAVE YOU SEEN A KAISER DOCTOR FOR THIS INJURY OR ILLNESS HAVE YOU SEEN ANY OTHER DOCTOR FOR THIS INJURY OR ILLNESS MOST RECENT DATE WORKED IF YES WHERE HOW DID YOU BECOME INJURED OR ILL DESCRIBE HOW IT HAPPENED AND WHAT PART S OF THE BODY ARE AFFECTED Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers compensation bene ts or payments is guilty of a felony. SIGNATURE FOR OFFICE USE ONLY INSURANCE VERIFICATION 96702 REV. 7-09 FOR SPANISH USE 08509-000 CHINESE 08509-001 DATE SIGNED. HAVE YOU COMPLETED AND RETURNED THE FORM TO YOUR EMPLOYER HAVE YOU SEEN A KAISER DOCTOR FOR THIS INJURY OR ILLNESS HAVE YOU SEEN ANY OTHER DOCTOR FOR THIS INJURY OR ILLNESS MOST RECENT DATE WORKED IF YES WHERE HOW DID YOU BECOME INJURED OR ILL DESCRIBE HOW IT HAPPENED AND WHAT PART S OF THE BODY ARE AFFECTED Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers compensation bene ts or payments is guilty of a felony. SIGNATURE FOR OFFICE USE ONLY INSURANCE VERIFICATION 96702 REV. 7-09 FOR SPANISH USE 08509-000 CHINESE 08509-001 DATE SIGNED.

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