Employees Disability Questionnaire
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Employees Disability Questionnaire Form. This is a California form and can be use in EDD Forms Workers Comp.
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Tags: Employees Disability Questionnaire, DEU 100, California Workers Comp, EDD Forms
STATE OF CALIFORNIA
Division of Workers' Compensation
Disability Evaluation Unit
EMPLOYEE'S DISABILITY QUESTIONNAIRE
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
Employer
Social Security No.
Nature of employer's business
Street and Number
City, State, Zip Code
Claim number
Date of Injury
Date of Birth
PLEASE ANSWER THE FOLLOWING QUESTIONS FULLY, using reverse side
if needed:
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?
Sign here __________________________________________Date: _______________________________
DEU Form 100
(Rev. 06-05)
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