| Page 2 Describe fully your regular job duties and physical requirements.________________________________ _____________________________________________________________________________________ ____________________________________________________________________________________ _____________________________________________________________________________________ Were you doing this work at the time of the injury? Yes ______ No_______ If not, describe what you were doing._______________________________________________________ ______________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Explain why you believe the injury is work related.___________________________________________ ____________________________________________________________________________________ Were there any witnesses to the injury? If so, please list below (include name and address and what they saw. 1. _____________________________________________________________________________ ____________________________________________________________________________________ 2. _________________________________________________________________________________ ___________________________________________________________________________________ Medical History Was health care sought? Yes______ No_______ If yes, who rendered treatment and when was health care given?_____________________________ __________________________________________________________________________________ _________________________________________________________________________________ If no, Why not?___________________________________________________________________ ________________________________________________________________________________ Have you seen your family doctor and/or specialists? If so, who and when.____________________ _________________________________________________________________________________ _________________________________________________________________________________ go to Page 3 |