Free Fishermen’s Fund, Carpal Tunnel Syndrome Questionnaire - Alaska

DEPT OF LABOR AND WORKFORCE DEVEOPMENT FISHERMEN'S FUND BOX 21149 JUNEAU AK 99802-1149 Questionnaire
I certify under penalty of perjury that : I
NAME ADDRESS

Carpal

Tunnel

Syndrome

of at
DATE TIME AM/PM

was injured on

at
GEOGRAPHIC LOCATION

while commercial fishing or working

on commercial fishing gear IN ALASKA. List number of years fished, type of fishing engaged in, how your injury/illness affected your ability to fish and a brief 10 year summary of your Alaska commercial fishing work history: (Please use additional sheets if necessary)

Explain other kinds of work and recreational activities performed when not engaged in commercial fishing (Please use additional sheets if necessary):

Explain why you waited so long to have your condition corrected:

Explain the extent of alternative treatment you may have pursued:

Do you believe your need for surgery is directly connected to your operations as a fisherman? __ Yes, __ No Please explain for either:

Dated at
CITY & STATE

this
DAY

of
MONTH YEAR

20 .

By
Signature