Post Hire Questionnaire For Second Injury Fund Qualification Form
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UESTIONNAIRE
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ECOND
NJURY
UND
UALIFICATION
The purpose of this questionnaire is to preserve the Employer’s right to obtain Second Injury Fund reimbursement if
you suffer a work-related injury in employment. If the resulting disability is greater due to aggravation of a pre-
existing condition, or because the injury combines with the pre-existing condition, the Employer may be able to
obtain reimbursement from the Fund of some workers’ compensation benefits paid to you. The completed
questionnaire will be retained in your confidential medical file. You may update the information at any time.
Department______________________
Name___________________________
Social Security No._________________________
Address_________________________
Date of Birth______________________________
________________________________
Telephone________________________________
Have you ever had, or do you now have, any of the following conditions? Note: this list is derived
from Alaska Statute 23.30.205. PLEASE COMPLETE BOTH COLUMNS.
YES
NO
YES
NO
____
____
EPILEPSY
____
____
DIABETES
____
____
MUSCULAR DYSTROPHY (any form)
____
____
HYPERINSULINISM
____
____
PARKINSON’S DISEASE
____
____
TUBERCULOSIS
____
____
POLIOMYELITIS residuals
____
____
LOSS OF SIGHT one or two eyes
____
____
CEREBRAL PALSY
____
____
VISION LOSS greater than 75%
____
____
CEREBRAL VASCULAR ACCIDENT(Stroke)
bilaterally, uncorrected
____
____
MULTIPLE SCLEROSIS
____
____
VARICOSE VEINS
____
____
CHRONIC OSTEOMYELITIS
____
____
THROMBPHLEBITIS
____
____
RUPTURED (HERNIATED) INTERVETEBRAL
____
____
ARTERIOSCLEROSIS
DISC (SPINAL DISK OR H.N.P.)
____
____
CARDIAC DISEASE of any kind
____
____
ANKYLOSIS OF JOINTS (Fused joints)
____
____
SILICOSIS
____
____
OSTEOPOROSIS
____
____
COMPRESSED AIR SEQUELAE
____
____
ARTHRITIS of any kind
____
____
HEAVY METAL POISONING
____
____
SPONDYLOLISTHESIS
____
____
IONIZING RADIATION INJURY
____
___
HEMOPHILIA
____
___
AMPUTATION foot, leg, arm,hand
Have you ever had, or do you now have any condition, disease or injury which resulted in 200 weeks or more of inability
to work? The 200 weeks need not be continuous. If your answer is yes, please briefly describe the condition or
injury.__________________________________________
Have you ever had a permanent impairment rating, single or combined, of 35% of the whole person or greater? If your
answer is yes, please state the condition or injury(ies) which led to the
rating._________________________________________________________________________
READ CAREFULLY, SIGN AND DATE:
I understand that the State is relying on me to be honest in my answers, and that concealment of a qualifying condition may
result in the State having to pay more for workers’ compensation benefits than it would if I had disclosed a qualifying
condition. I have answered the above questions to the best of my knowledge. I understand that if I knowingly make a false
statement regarding my physical condition, I may not receive Workers’ Compensation benefits under AS 23.30, the Alaska
Workers’ Compensation Act. I understand that this information will be kept in my confidential medical file and will be used for
workers’ compensation purposes only.
Signed ______________________________________________________________ Dated ____________________
Rev. May 2005
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