Worker Compensation Form

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WORK HISTORY, WORK QUALIFICATIONS
& TRAINING DISCLOSURE QUESTIONNAIRE
Michigan Department of Licensing and Regulatory Affairs
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 parti e s’ rights to request further disclosure as provided in
that decision.
SECTION 1 – GENERAL INFORMATION
1. Name (First, Middle Initial, Last)
2. Social Security Number (Last four digits only)
XXX-XX-
3. Street Address
4. City
5. State
6. ZIP Code
7. Do you have a valid driver’s license?
Yes
No
If yes, issuing state ______________
Expiration date _________
Special endorsements or restrictions ___________________
If no, do you have a valid government issued photo I.D. card?
Yes
No
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?
Yes
No
If yes, please describe:
12. Can you read and write English? For example, can you read this form, newspapers, magazines etc.?
Yes
No
13. For each school you attended, provide the following information (please attach additional pages if necessary):
Address if known
Grade
Degree/
Course
Years
School Name
or City & State
Completed
Diploma
of Study
Attended
High School
Vocational
School
College
Post-graduate
14. Have you completed any type of special job training, trade or vocational school?
Yes
No
a.
Type of training
b.
Date completed
c.
Certifications/licenses received
d.
Expiration date of certification/licenses
1

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