Free DWC -AD Form 100 DEU - California

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STATE OF CALIFORNIA Division of Workers' Compensation Disability Evaluation Unit EMPLOYEE'S DISABILITY QUESTIONNAIRE
DEU Use Only

This form will aid the doctor in determining your permanent impairment or disability. Please complete this form and give it to the physician who will be performing the evaluation. The doctor will include this form with his or her report and submit it to the Disability Evaluation Unit, with a copy to you and your claims administrator.

Employee First Name MI

Last Name

SSN (Numbers Only) Street Address 1/PO Box (Please leave blank spaces between numbers, names or words)

Street Address 2/PO Box (Please leave blank spaces between numbers, names or words) International Address (Please leave blank spaces between numbers, names or words)

City Date of Birth
MM/DD/YYYY

State

Zip Code

Date of Injury
MM/DD/YYYY

Employer

Nature of Employers Business Claim Number 1

DWC-AD form100 (DEU) Page 1 (REV. 11/2008)

DWC-AD form100 (DEU)

Claim Number 2

Claim Number 3 Claim Number 4 Claim Number 5 PLEASE ANSWER THE FOLLOWING QUESTIONS FULLY: How was your evaluating doctor selected? (check one) From a list of doctors provided by the State of California, Division of Workers' Compensation. Other (explain)

What is the name of the doctor who will be doing the evaluation? When is your examination scheduled? What were your job duties at the time of your injury?

What is the disability resulting from your injury?

How does this injury affect you in your work?

Have you ever had a disability as a result of another injury or illness? If so, when? Please describe the disability?

Date

MM/DD/YYYY

Signature ____________________________________________ DWC-AD form100 (DEU)

DWC-AD form100 (DEU) Page 2 (REV. 11/2008)