Free WORKERS' COMPENSATION AGENCY - Michigan

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WORK HISTORY, WORK QUALIFICATIONS & TRAINING DISCLOSURE QUESTIONNAIRE
Michigan Department of Energy, Labor & Economic Growth Workers' Compensation Agency P O Box 30016, Lansing, MI 48909 The information you disclose in this questionnaire may be used by the magistrate to facilitate exchange of information as required by Stokes v. Chrysler, LLC, 481 Mich 266 (2008). Completion is voluntary. Completed forms should be exchanged among all parties and not sent to the Workers' Compensation Agency. Use of this questionnaire does not limit the parties' rights to request further disclosure as provided in that decision.

SECTION 1 ­ GENERAL INFORMATION
1. Name (First, Middle Initial, Last) 3. Street Address 4. City 2. Social Security Number (Last four digits only) XXX-XX5. State 6. ZIP Code

7. Do you have a valid driver's license? If yes, issuing state ______________

Yes

No Special endorsements or restrictions ___________________ Yes No

Expiration date _________

If no, do you have a valid government issued photo I.D. card?

SECTION 2 ­ EDUCATIONAL / VOCATIONAL/MILITARY BACKGROUND
8. Indicate the highest grade of school you have completed (0-12): ______________________ 9. Did you graduate from high school? Yes No If yes, what year did you graduate? _______________

10. If you obtained a GED, what year did you obtain it (either the specific year or best estimate)? _________________________ 11. Do you have any other disabilities that might be a barrier to employment? If yes, please describe: Yes No

12. Can you read and write English? For example, can you read this form, newspapers, magazines etc.? 13. For each school you attended, provide the following information (please attach additional pages if necessary):
School Name Address if known or City & State Grade Completed Degree/ Diploma Course of Study

Yes

No

Years Attended

High School Vocational School College Post-graduate 14. Have you completed any type of special job training, trade or vocational school? a. b. c. d. Type of training Date completed Certifications/licenses received Expiration date of certification/licenses Yes No

1

Name
15. Computer Experience/Access Please describe any computer skills/experience/training you have:

___________________________________

a. b. c. d.

Do you have access to the Internet? Do you have an e-mail address? Can you send and receive e-mail? Are you proficient in any of the following computer programs: i. ii. iii. iv. Microsoft Excel Microsoft Works Microsoft Word Microsoft Money

Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No

e.

Are you proficient in any computer programs other than those named above? If yes, please identify those programs in which you are proficient:

16. For any volunteer activities or hobbies in which you have participated, provide the following information:
Activity/Organization Years of Involvement Describe Your Activities

17. Have you been involved in any non-work activities in which you have had a leadership position, such as club president, committee chairperson, etc.? If yes, please provide the following information (please attach additional pages if necessary):
Activity/Organization Years of Involvement

Yes

No

Describe your activities

18. Have you served in the U.S. military?

Yes

No Dates _______________________________________

Branch _____________________________________________

Specialized training _______________________________________________________________________________________ If you were in the Army, list your Military Occupational Specialty (MOS) code; for the Air Force list your Air Force Specialty Code (AFSC); for the Navy, Marine Corps or Coast Guard, list your rank and type of discharge: _________________________________

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SECTION 3 ­ EMPLOYMENT EXPERIENCE
19. List in chronological order each and every job you have had since age 18, including any periods of self-employment, and provide the information requested. In addition, you are to complete one "Job Detail Form" for each job you list. If you have had more than five (5) jobs since age 18, please list the additional jobs on another sheet of paper. You may photocopy the Job Detail Form so that you have one form for each job you list. Employer 1. 2. 3. 4. 5. Please list additional employers on another sheet of paper. 20. Union Employment. Do you now or have you ever worked through or out of a union hall? If yes, please provide the following information (please attach additional pages if necessary): Union Name Local Number Address if known or City & State Yes No Address if known or City & State Type of Business Job Title(s) Dates of Employment to to to to to

The above information, including any attachments, is true to the best of my knowledge. I understand that the information disclosed in this questionnaire may be used by the magistrate in determining my entitlement to workers' compensation benefits.

Signature of Claimant ____________________________________________ Date ________________________________ (Claimant must sign)

Claimant's Name _______________________________________________ (Printed or typed)

IF YOU HAVE ATTACHED ANY ADDITIONAL PAGES, PLEASE INCLUDE YOUR FULL NAME AND THE LAST FOUR DIGITS OF YOUR SOCIAL SECURITY NUMBER ON EACH ADDITIONAL PAGE.
Completed forms should be exchanged among all parties and not sent to the Workers' Compensation Agency.

DELEG is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-105A (3/09) www.michigan.gov/wca

Authority: Completion: Penalty:

418.205, 418.221, R408.40b(2) Voluntary None

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JOB DETAIL FORM
Please complete one Job Detail Form for each job listed in Section 3, question 19. JOB # __________________ Employer's Name (include any self-employment) Employer's Street Address Dates of Employment Rate of Pay $ _______________ per Hour Day Week Month Year City State ZIP Code

Hours per day ____________________________

Days per week _______________________________

Describe this job. In this job, how many total hours each day did you: Walk ________ Stand ________ Sit ________ ________ ________ ________ Climb ________ Reach ________ ________ ________ ________

Stoop (Bend down & forward at waist) Kneel (Bend legs to rest on knees) Crouch (Bend legs & back down & forward)

Crawl (Move on hands & knees) Handle, grab or grasp big objects Write, type or handle small objects

Lifting and Carrying. Explain what you lifted, how far you carried it, and how often you did this.

Check the heaviest weight lifted: Less than 10 lbs. 10 lbs. 20 lbs. 50 lbs. 100 lbs. or more Other __________

Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.) Less than 10 lbs. 10 lbs. 25 lbs. 50 lbs. or more Yes Other __________ No

Did this job require you to work with the public? If yes, describe: Did this job require you to use machines, tools or equipment? If yes, describe: Did this job require you to use technical knowledge or skills? If yes, describe: Did this job require you to perform any duties such as writing, completing reports, etc.? If yes, describe: Did this job require you to supervise other people? If yes, describe:

Yes

No

Yes

No

Yes

No

Yes

No

Signature of Claimant ____________________________________________ Date ________________________________ (Claimant must sign) Claimant's Name _____________________________________ (Printed or typed)
WC-105A (3/09)

Social security number XXX-XX-_______________ (last 4 digits)