Free Occupational Disease & Employment History - Washington

Department of Labor and Industries Claims Section PO Box 44291 Olympia WA 98504-4291

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Name

OCCUPATIONAL DISEASE & EMPLOYMENT HISTORY
Claim Number

Occupational Disease History
What is the medical condition for which you are filing this claim? When were you first told by a doctor that your Month / Year symptoms were caused by your job? When did you first notice you had these symptoms? Have you ever seen any other doctor for these symptoms? Have you ever had any medical tests for these symptoms? What symptoms do you have? Month / Year Yes Yes No No

Name of doctor who told you that your symptoms are related to your job: (print or type) Address City State ZIP+4

Please complete the attached medical records release forms so that we can obtain your records. Is your completed release attached? Yes No Type of work you perform that you believe caused your symptoms:

If the release is not completed, your claim for benefits will be delayed or may be rejected. Month / Year

Start date of employment at the first job you think caused your symptoms. What activity did you perform at work that you believe caused your symptoms? (Please check all that apply) Gripping or Pinching Forceful activity Repetitive tasks (describe) Other (describe) Pulling Pushing Kneeling Reaching overhead Tools used Twisting with my

Employment History
Please start with your most RECENT job and work BACKWARDS Include all current and past employment. All dates should be your best estimate. You must list any breaks or interruptions in your work history.
Employer's business name Employer's address City State ZIP+4 Your job title Employer's phone number Employment Dates: From (mo/yr) To (mo/yr)

How many hours per week did you perform the activity you believe caused your symptoms? hours Describe the job duties, tool use or repetitive activities done on a regular basis. Include approximately how much time per day you spent doing each activity Indicate any break or interruption in your work history during this job or between this job and the next. Reason for interruption:
Employer's business name Employer's address City State ZIP+4 Your job title Employer's phone number From (mo/yr) To (mo/yr) From (mo/yr) To (mo/yr)

Employment Dates:

How many hours per week did you perform the activity you believe caused your symptoms? hours Describe the job duties, tool use or repetitive activities done on a regular basis. Include approximately how much time per day you spent doing each activity Indicate any break or interruption in your work history during this job or between this job and the next. Reason for interruption: I certify that the information is true and correct to the best of my knowledge.
Page 1 of Date: Signature: From (mo/yr) To (mo/yr)

F242-071-000 occupational disease work history 10-05