Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part III - Workers' Compensation Second Injury Board
Chapter 5 - Forms
Section III-502 - Louisiana Workers' Compensation Second Injury Board Post-Hire/Conditional Job Offer Knowledge Questionnaire; Form D
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.
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1291 and R.S. 23:1378.
