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Fill Out Your Second Injury Questionnaire Form

The Second Injury Questionnaire is a form designed to inform employers of any pre-existing medical conditions or disabilities that an employee may have. This information is crucial as it can facilitate the employer's eligibility for reimbursement from the Louisiana Workers’ Compensation Second Injury Board in the event of a workplace injury. While this reimbursement does not impact the employee's benefits, it is vital that the information provided is accurate, as misleading or incorrect answers may jeopardize workers’ compensation benefits.

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Article Structure

The Louisiana Workers' Compensation Second Injury Questionnaire is an important document that serves to inform employers about any pre-existing medical conditions or disabilities of potential employees. This questionnaire helps an employer determine eligibility for reimbursement from the Louisiana Workers' Compensation Second Injury Board should an employee sustain an on-the-job injury. By disclosing relevant medical histories, employees enable their employers to take advantage of potential financial protections while ensuring compliance with state regulations. It’s crucial to complete the form accurately, as any false or incomplete information could lead to losing workers' compensation benefits. The questionnaire includes sections for personal information, a comprehensive list of medical conditions, surgical history, and a shareable explanation page for additional details. Employees are encouraged to request confidentiality for their medical information, ensuring it remains separate from their personnel files. Signature lines for both the employee and employer representatives emphasize the importance of honesty and transparency throughout the process.

Second Injury Questionnaire Example

LOUISIANA WORKERS’ COMPENSATION SECOND INJURY BOARD

POST‐HIRE/CONDITIONAL JOB OFFER KNOWLEDGE QUESTIONNAIRE

EMPLOYEE: The intent of this questionnaire is to provide your employer with knowledge about any pre‐ existing medical condition or disability which may entitle your employer to reimbursement from the Louisiana Workers’ Compensation Second Injury Board in the event you suffer an on‐the‐job injury.1 This reimbursement in no way affects the benefits owed to you by your employer or its insurance company under the Louisiana Workers’ Compensation Act. La. R.S. 23:1021‐1361. However, your failure to answer truthfully and/or correctly to any of the question on this questionnaire may result in a forfeiture of your workers’ compensation benefits.

In order for your employer to be considered for reimbursement from the Second Injury Board, it has to show that it knowingly hired or retained you with a pre‐existing medical condition or disability. To establish its knowledge, your employer is requesting that this questionnaire be completed.

INSTRUCTIONS: Please answer ALL questions completely. If a response requires an explanation, please provide a brief description on the Explanation Page. If you have any questions or need help in answering the questions on this form, please ask for assistance from the Employer Representative signing this form.

NOTE: Since this questionnaire contains medical information, you can request that the form be kept CONFIDENTIAL and not made part of your personnel file. Please let your employer know that you want the completed questionnaire placed in a sealed folder for confidentiality purposes.

EMPLOYEE WARNING

FAILURE TO ANSWER TRUTHFULLY AND/OR CORRECTLY TO ANY OF THE QUESTIONS ON THIS FORM MAY RESULT IN A FORFEITURE OF YOUR WORKERS’ COMPENSATION BENEFITS UNDER La. R.S. 23:1208.1.

Employee Signature: _____________________________________________________	Date:	_____________
Employer Representative Signature: ________________________________________	Date:	_____________

Employer Name: ____________________________________________________________________________

Employee Name:____________________________________________________________________________

Date of Birth (mm/dd/yyyy): ____________	Male:	Female:
Soc. Sec. # (last 4 digits only): ____________

Home Address: _____________________________________________________________________________

Telephone Number: ( ____ ) __________________

1Under La. R.S. 23:1371(A), the purpose of the Second Injury Board is to encourage the employment, re‐ employment, or retention of employees who have a permanent partial disability.

PAGE 1 OF 6

SIB FORM D (10/17)

Disease and Other Medical Conditions you currently have or have ever had.

For all conditions that you check yes, write a brief explanation on the Explanation Page.

[Please check the appropriate box next to each. Every illness/injury requires a Yes (Y) or No (N) answer.]

Y N	Y N	Y N
  Diabetes	  Cerebral Palsy	  Arthritis
  Silicosis	  Tuberculosis	  Parkinson’s
  Varicose Veins	  Multiple Sclerosis	  Brain Damage
  Asbestosis	  Post Traumatic Stress	  Asthma
  Hyperinsulinism	  Osteomyelitis	  Dementia
  Alzheimer’s	  Nervous Disorder	  Thrombophlebitis
  Emphysema	  Muscular Dystrophy	  Arteriosclerosis
  Hearing Loss	  Migraine Headaches	  Hodgkin’s
  COPD	  Mental Retardation	  Cancer
  Hypertension	  Kidney Disorder	  Double Vision
  Head Injury	  Loss of Use of Limb	  Mental Disorders
  Epilepsy	  Seizure Disorder	  Hemophilia
  Stroke	  Sickle Cell Disease	  Bleeding Disorder

Y N

 Heart Disease/Heart Attack

 Congestive Heart Failure

 Vision Loss, one or both eyes

 Disability from Polio

 Psychoneurotic Disability

 Ruptured or Herniated Disc

 Ankylosis or Joint Stiffening

 High/Low Blood Pressure

 Carpal Tunnel Syndrome

 Compressed Air Sequelae

 Disease of the Lung

 Coronary Artery Disease

 Heavy Metal Poisoning

Surgical Treatment [Please check the appropriate box. Each illness/injury requires a Yes (Y) or No (N) answer.] For each Yes (Y) answer, please complete the information corresponding to the surgery on the right. Additional information can be provided on the Explanation Page, if necessary.

Y N
Spinal Disc Surgery	Year (approximate if unsure)___________
Spinal Fusion Surgery	Year (approximate if unsure)___________
Amputated Foot	Left	Right	Year (approx. if unsure) ___________
Amputated Leg	Left	Right	Year (approx. if unsure) ___________
Amputated Arm	Left	Right	Year (approx. if unsure) ___________
Amputated Hand	Left	Right	Year (approx. if unsure) ___________
Knee Replacement	Left	Right	Year (approx. if unsure) ___________
Hip Replacement	Left	Right	Year (approx. if unsure) ___________
Other Joint Replacement	Joint ________________________ Year ________________
Other Surgical Procedure	Procedure ___________________ Year ________________
Other Surgical Procedure	Procedure ___________________ Year ________________
Other Surgical Procedure	Procedure ___________________ Year ________________
Other Surgical Procedure	Procedure ________		Year ________________

Employee Signature: ________________________________________	Date: _________________________
Employer Representative: ___________________________________	Date: _________________________
	PAGE 2 OF 6
	SIB FORM D (10/17)

EXPLANATION PAGE

Please use the space below to explain the illnesses and/or conditions that you checked a Yes (Y) or any other medical conditions that may not be listed on this form. Ask your employer for additional copies of this page if needed.

CONDITION: ____________________________________________________ Year Diagnosed (approx):_______________

Are you still treating for this condition?	Yes	No
Are you taking medication for this condition?	Yes	No
Do you have any permanent restrictions for this condition?	Yes	No

Brief Explanation: ___________________________________________________________________________________

CONDITION: ____________________________________________________ Year Diagnosed (approx):_______________

Are you still treating for this condition?	Yes	No
Are you taking medication for this condition?	Yes	No
Do you have any permanent restrictions for this condition?	Yes	No

Brief Explanation: ___________________________________________________________________________________

CONDITION: ____________________________________________________ Year Diagnosed (approx):_______________

Are you still treating for this condition?	Yes	No
Are you taking medication for this condition?	Yes	No
Do you have any permanent restrictions for this condition?	Yes	No

Brief Explanation: ___________________________________________________________________________________

CONDITION: ____________________________________________________ Year Diagnosed (approx):_______________

Are you still treating for this condition?	Yes	No
Are you taking medication for this condition?	Yes	No
Do you have any permanent restrictions for this condition?	Yes	No

Brief Explanation: ___________________________________________________________________________________

Employee Signature: ________________________________________	Date: _________________________
Employer Representative: ___________________________________	Date: _________________________

PAGE 3 OF 6

SIB FORM D (10/17)

Please answer the following questions.

1. Has any doctor ever restricted your activities? Yes No

If “Yes,” please list the restrictions: __________________________________________________________

Were the restrictions: Permanent	Temporary
Are your activities currently restricted?	Yes	No

What is the medical condition for which you have restrictions? ____________________________________

2. Are you presently treating with a doctor, chiropractor, psychiatrist, psychologist or other health‐care

provider? Yes No

Please list the medical condition being treated: ________________________________________________

Doctor’s Name: ________________________________Specialty: __________________________________

Doctor’s Address: ________________________________________________________________________

3.If you are currently taking prescription medication other than those listed on the Explanation Page, please complete the requested information below.

Medication: ___________________________________Prescribing Doctor: __________________________

4. Have you ever had an on the job accident? Yes No

If you answered “YES,” please provide the date for each injury and the nature of the injury:

_______________________________________________________________________________________

How long were you on compensation? _________________________

Name of Employer: _______________________________________________________________________

5. Has a doctor recommended a surgical procedure, which has not been completed prior to this date, including but not limited to knee, hip or shoulder replacement? Yes No

If you answered YES, please provide:

Recommended surgery: _____________________________________

Approximate date of recommendation:_________________________

Doctor’s Name: ________________________________Specialty: __________________________________

Doctor’s Address: ________________________________________________________________________

Employee Signature: ________________________________________	Date: _________________________
Employer Representative: ___________________________________	Date: _________________________
	PAGE 4 OF 6
	SIB FORM D (10/17)

TO BE COMPLETED BY EMPLOYEE

EMPLOYEE WARNING

FAILURE TO ANSWER TRUTHFULLY AND/OR CORRECTLY TO ANY OF THE QUESTIONS ON THIS FORM MAY RESULT IN A FORFEITURE OF ANY AND ALL WORKERS COMPENSATION BENEFITS UNDER La. R.S. 23:1208.1.

I have completed this form honestly and to the best of my knowledge. I understand that providing false information or omitting pertinent information could result in loss of my workers compensation benefits should I become injured on the job.

Employee Signature: _____________________________________________________ Date: _____________

Employee Printed Name: _____________________________________________________________________

PAGE 5 OF 6

SIB FORM D (10/17)

TO BE COMPLETED BY EMPLOYER REPRESENTATIVE

EMPLOYER WARNING

PURSUANT TO La. R.S. 23:1208 OF THE LOUISIANA WORKERS’ COMPENSATION ACT, IT SHALL BE UNLAWFUL FOR A PERSON, FOR THE PURPOSE OF OBTAINING OR DEFEATING ANY BENEFIT PAYMENT UNDER THE PROVISIONS OF THIS CHAPTER, EITHER FOR HIMSELF OR FOR ANY OTHER PERSON, TO WILLFULLY MAKE A FALSE STATEMENT OR REPRESENTATION. PENALTIES FOR VIOLATIONS INCLUDE IMPRISONMENT, FINES, AND/OR THE FORFEITURE OF BENEFITS.

You must certify the following:

1.That I am an authorized representative of the employer designated to obtain and review the information provided by the employee on this questionnaire;

2.That I have provided the employee with as many copies of the Explanation Page as needed and have confirmed the number of and labeled the pages of this questionnaire;

3.That I have provided assistance to the employee (if requested) in responding to the questions on this questionnaire;

4.That the information sought by this authorization is made on an applicant for employment only after a conditional job offer has been made and accepted, or on a current employee; and

5.That the information obtained in the authorization will NOT be used to discriminate in any manner against the individual who is the subject of this authorization on any basis, in violation of the Americans with Disabilities Act of 1990, 42 U.S.C. §12101, et seq., or any other state or federal law;

6.That if requested, a photocopy of this fully completed and signed form will be provided to the employee.

Employer Representative Signature:__________________________________________ Date: _____________

Employer Representative Printed Name: _________________________________________________________

Title: _____________________________________________________________________________________

PAGE 6 OF 6

SIB FORM D (10/17)

Get Second Injury Questionnaire PDF Form

Form Characteristics

Fact Name	Details
Purpose of the Form	The Second Injury Questionnaire is designed to gather information about an employee's pre-existing medical conditions or disabilities. This information helps the employer determine eligibility for reimbursement from the Louisiana Workers’ Compensation Second Injury Board if the employee suffers an on-the-job injury.
Confidentiality	Employees can request that their completed questionnaire be kept confidential. This request can be made to ensure the form does not become part of their personnel file.
Consequences of Misrepresentation	Failure to answer the questions truthfully may lead to a forfeiture of workers' compensation benefits. It is crucial for employees to provide accurate information when completing the form.
Governing Laws	This form operates under the Louisiana Workers' Compensation Act (La. R.S. 23:1021-1361) and the specific provision regarding forfeiture for untruthful responses (La. R.S. 23:1208.1).

Guidelines on Utilizing Second Injury Questionnaire

Completing the Second Injury Questionnaire is an important process for ensuring your employer can effectively address any pre-existing medical conditions or disabilities. This form requires honesty and clarity, as accurate information is crucial for potential reimbursement claims. Here’s a straightforward guide to help you fill out the form correctly.

Begin by filling in your personal information at the top of the form, including your full name, date of birth, and social security number (last four digits). Make sure to check either the male or female box.
Next, provide your home address and telephone number. Be certain that all contact details are current and accurate for communication purposes.
Move on to the section concerning disease and medical conditions. For each condition listed, indicate whether you have or have ever had it by checking 'Yes' or 'No'. Each condition requires a response.
If you answered 'Yes' to any condition, use the Explanation Page to provide additional details about that condition, including how it affects you and any relevant treatment history.
In the surgical treatment section, check 'Yes' or 'No' for each type of surgery. For those you confirm having undergone, fill in the approximate year of the surgery.
Complete the Explanation Page by detailing any additional medical conditions that are not listed on the form, including treatment status and any permanent restrictions you may have.
Answer the additional questions about past medical restrictions, current treatments, and any medications you are taking. This information is necessary for your employer to assess your situation properly.
If applicable, provide details of any past job-related injuries or accidents, including the date and nature of the injuries.
Finally, review the entire form for accuracy. After ensuring everything is correct, sign and date the bottom of the form.

Once you have completed the questionnaire, submit it to your employer for processing. If you have requested confidentiality, remind them to store your form in a sealed folder. This step is particularly significant as it ensures your medical information is protected.

What You Should Know About This Form

What is the purpose of the Second Injury Questionnaire?

The Second Injury Questionnaire is designed to inform your employer about any pre-existing medical conditions or disabilities you may have. This information is crucial as it may allow your employer to seek reimbursement from the Louisiana Workers’ Compensation Second Injury Board if you incur an injury while on the job. The questionnaire aims to establish whether your employer knowingly hired or retained you despite these conditions.

What happens if I do not complete the questionnaire truthfully?

Honesty is critical when filling out the questionnaire. Failing to provide truthful or accurate information may result in the forfeiture of your workers’ compensation benefits. It is essential to understand that any discrepancies could adversely affect your rights if you suffer a work-related injury.

Can I request confidentiality for my medical information?

Yes, you have the right to request that your completed questionnaire be kept confidential. You can inform your employer that you want the document placed in a sealed folder for confidentiality purposes, ensuring that it does not become part of your regular personnel file.

What types of medical conditions should I disclose?

The questionnaire includes a list of various medical conditions, such as diabetes, arthritis, and heart disease, among others. You should disclose any current or past medical conditions that apply to you. If you select “Yes” for any condition, you will be asked to provide further details on the Explanation Page.

What should I do if I have questions about the questionnaire?

If you have questions or need assistance while completing the questionnaire, feel free to ask the employer representative who is signing the form. They are there to help clarify any items you may find confusing or unclear.

What type of surgeries do I need to report?

You should report any surgical procedures you have undergone, including but not limited to spinal disc surgery, knee replacements, and amputations. The questionnaire provides specific sections for noting these surgeries, and if applicable, it asks for the approximate year of the procedure.

Are there risks associated with not disclosing an on-the-job injury?

Yes, failing to disclose any previous on-the-job injuries could impact your ability to receive benefits in the event of a subsequent injury. The questionnaire asks if you have previously experienced any job-related accidents, and providing this information is important to maintain transparency.

How does this questionnaire affect my workers' compensation benefits?

The information gathered through the Second Injury Questionnaire is used to determine your employer's eligibility for reimbursement from the Second Injury Board. However, it does not affect the benefits you are entitled to receive under the Louisiana Workers’ Compensation Act. You will still have access to all benefits owed to you by your employer or their insurance company.

What should I do after completing the questionnaire?

After you complete the questionnaire, you will need to sign it along with an employer representative. Ensure that all sections are filled out completely, and be mindful of your request for confidentiality if applicable. Keep a copy of the completed questionnaire for your records.

Common mistakes

Completing the Second Injury Questionnaire form accurately is essential for receiving appropriate workers' compensation benefits. However, many individuals make mistakes that may jeopardize their claims. Here are nine common errors to avoid.

First, failing to read the entire form before answering is a frequent issue. Rushing through the questions can lead to incomplete or incorrect answers. Each question is designed to gather crucial information, so taking the time to understand what is being asked is essential.

Second, some respondents don't provide sufficient detail in the explanation sections. When a medical condition is marked "Yes," a brief explanation is required on the Explanation Page. Neglecting to offer clarity can create confusion and may lead to unnecessary complications during the review process.

Another common mistake is not disclosing past injuries or medical conditions thoroughly. Honesty is critical. Undisclosed information can be viewed as deceitful if discovered later, which could lead to significant legal and financial repercussions.

Additionally, some individuals check "No" when they should say "Yes." This error often occurs when people overlook their medical history. A forgotten condition, even if it seems minor, could have implications for the employer's second injury claim.

Moreover, misunderstanding the distinction between permanent and temporary conditions can also result in errors. It is vital to accurately classify the nature of restrictions and conditions. Misrepresentation may cast doubt on the rest of your answers.

Another mistake involves the lack of consistency in answers throughout the form. If respondents claim to have never had any restrictions in one section but mention restrictions in another, this inconsistency can draw attention and lead to further scrutiny.

Incorrectly filling out personal information, such as the date of birth, social security number, or contact details, is also a significant error. These details must be accurate to ensure the smooth processing of the questionnaire.

Lastly, neglecting to sign and date the form or failing to get a witness signature can invalidate the submission. It is crucial to sign after confirming that all answers are complete and truthful to avoid potential loss of benefits.

By avoiding these mistakes, individuals can help ensure that their completion of the Second Injury Questionnaire form is accurate and effective. Careful attention to detail will facilitate a smoother processing experience for all parties involved.

Documents used along the form

The Second Injury Questionnaire form plays a crucial role in the Workers' Compensation process, especially for employers seeking reimbursement for pre-existing conditions. It’s essential to navigate the relevant documentation that accompanies this form to ensure proper handling of workers’ compensation claims. Here’s a list of additional forms and documents often used alongside the Second Injury Questionnaire.

Workers' Compensation Claim Form: This form is typically filed by an employee to officially report a work-related injury or illness. It captures details about the incident, medical treatment, and the employee’s information necessary for processing the claim.
Medical Authorization Release Form: This document authorizes medical providers to share an employee's health information with the employer and the Workers' Compensation insurer, facilitating the claim review process.
Employer's Report of Injury Form: Used by employers to document occurrences of workplace injuries, this report includes information about the injury, the employee’s work capacity, and subsequent actions taken post-incident.
Injury Record Log: Employers maintain this ongoing log to track all workplace injuries for compliance and reporting purposes. It helps to monitor and manage safety within the work environment.
Pre-Existing Condition Disclosure Form: This form may be required to outline any conditions that may affect the employee’s ability to work or modify tasks, ensuring full disclosure for the safety of the employee and compliance with workplace policies.
Return to Work Release Form: After an injury, employees must often provide this form completed by their healthcare provider, certifying their readiness to return to work and outlining any restrictions or accommodations needed.
Explanation Page: As mentioned in the Second Injury Questionnaire, this page allows employees to provide additional information regarding their medical history or conditions that might not fit within the initial questionnaire, ensuring transparency in the evaluation process.

Understanding these forms can streamline the workers' compensation process and ensure clarity in communication between all parties involved. Properly addressing these documents helps protect both the employee’s rights and the employer’s interests.

Similar forms

The Second Injury Questionnaire form serves a pivotal role in the context of workers' compensation in Louisiana. Its purpose is to collect comprehensive medical information from employees to inform employers about any pre-existing conditions that may impact potential claims. Similar forms are often used in varied but related contexts within the realm of employment and healthcare. The following documents exhibit similarities to the Second Injury Questionnaire:

Workers’ Compensation Claim Form: Much like the Second Injury Questionnaire, this document is designed to provide pertinent information regarding an employee's medical history and any previous injuries. It outlines necessary details to facilitate the filing of a claim and ensure relevant benefits are granted.
Pre-Employment Health Questionnaire: This form requires potential employees to disclose medical conditions before being hired. It aims to inform employers about any health issues that could impact job performance, similar to how the Second Injury Questionnaire aims to assess pre-existing conditions for better handling of future claims.
Return-to-Work Evaluation Form: When an employee seeks to return to work after an injury, this document evaluates their current health status and any limitations they may have. It is comparable to the Second Injury Questionnaire in its focus on understanding an employee's medical condition in relation to their work capabilities.
Disability Disclosure Form: This form allows employees to report disabilities that may affect their job functions. Intended for similar purposes of transparency regarding an employee's health condition, it connects to the Second Injury Questionnaire through its focus on fostering an understanding between employee and employer regarding potential challenges in the workplace.

Dos and Don'ts

When filling out the Second Injury Questionnaire form, here are four important do's and don'ts:

Do: Answer all questions completely. Every piece of information counts and can affect your benefits.
Do: Provide brief explanations for any "Yes" responses on the Explanation Page. Clarity is key.
Do: Ask your Employer Representative for help if you're unsure about any questions. It's better to seek guidance than to guess.
Do: Request that the completed questionnaire be kept confidential. This can protect your privacy.

Don't: Leave any question unanswered. Incomplete responses can lead to issues with your benefits.
Don't: Provide false information. This can result in a loss of workers' compensation benefits.
Don't: Assume your employer knows about your pre-existing conditions. Be open and thorough in your disclosure.
Don't: Forget to sign and date the form. An unsigned form can lead to complications.

Misconceptions

There are several misconceptions regarding the Second Injury Questionnaire form that may lead to confusion among employees who are required to complete it. Understanding these misconceptions can help ensure that the form is filled out correctly and that employees' rights are protected.

The questionnaire is optional. Many employees believe that completing the Second Injury Questionnaire is not mandatory. In reality, filling out this form is essential for employers to seek reimbursement from the Louisiana Workers’ Compensation Second Injury Board.
False information does not have consequences. Some individuals think they can answer questions untruthfully without repercussions. This is incorrect; dishonest or inaccurate responses may lead to a forfeiture of workers’ compensation benefits.
All medical conditions need to be disclosed. Employees might assume they must disclose every medical condition, no matter how minor. The form only requires disclosure of pre-existing conditions that are relevant to the employer’s awareness of potential injuries.
The information is public. There is a common belief that the information shared in the Questionnaire will be publicly accessible. However, employees can request that their responses be treated confidentially and kept separate from personnel files.
It only concerns past injuries. Some individuals think the form is solely for reporting prior injuries. This form also encompasses medical conditions and surgeries that might not have resulted in an injury but are relevant to the employee's overall health.
Employers review this form after an injury occurs. Many employees do not realize that the form needs to be completed as a proactive measure before any work-related injuries, so that employers can establish their knowledge regarding pre-existing conditions ahead of time.
The employer cannot ask for additional details. Employees might feel that the form limits them in terms of explaining their conditions. However, the form encourages providing explanations on the designated Explanation Page, allowing for more comprehensive information.
The form's purpose is punitive. Some believe that the Questionnaire is intended to penalize employees for prior conditions. In truth, its purpose is to protect both the employer and employee by clarifying pre-existing conditions that could affect future claims.
Completing the form is burdensome. There's a perception that the Questionnaire is overly complex or time-consuming. With clear instructions in place, employees can easily complete it and ask for assistance if needed.
Information on the form is irrelevant after submission. Employees may think that once the form is submitted, it is no longer of significance. In reality, it plays a crucial role in determining any future benefits and should be taken seriously throughout all stages of employment.

Key takeaways

The Second Injury Questionnaire is designed to inform your employer about any pre-existing medical conditions or disabilities. This helps them potentially receive reimbursement from the Louisiana Workers’ Compensation Second Injury Board if you sustain an injury at work.
Completing the questionnaire honestly is crucial. Any failure to provide truthful or accurate information may lead to loss of workers’ compensation benefits.
This form requires you to answer all questions completely. If an answer requires further explanation, additional details should be provided on the Explanation Page.
Confidentiality is an important aspect of this questionnaire. You have the right to request that it be kept confidential and separate from your personnel file.
Your employer must demonstrate that they hired or kept you on with knowledge of your pre-existing conditions. Therefore, completing this form accurately is in your best interest.
Be prepared to provide details about any medical conditions checked as “Yes.” You should also include information about any necessary treatments or surgeries.
If you have had previous injuries, report them carefully in the questionnaire. Disclosing past accidents ensures your employer fully understands your medical history.
It is advisable to seek assistance from your Employer Representative if you have questions while filling out the questionnaire. Help is available to ensure that everything is understood and completed correctly.

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