WORK HISTORY, WORK QUALIFICATIONS & TRAINING DISCLOSURE QUESTIONNAIRE Michigan Department of Labor & Economic Growth 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 parties’ 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) 3. Street Address XXX-XX5. State 4. City 7. Do you have a valid driver’s license? If yes, issuing state ______________ Yes 6. ZIP Code No Expiration date _________ If no, do you have a valid government issued photo I.D. card? Special endorsements or restrictions ___________________ 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): School Name Address if known or City & State Grade Completed Degree/ Diploma Course of Study Years Attended High School Vocational School College Post-graduate 14. Have you completed any type of special job training, trade or vocational school? a. Date completed c. Certifications/licenses received d. No Type of training b. Yes Expiration date of certification/licenses 1 American LegalNet, Inc. www.FormsWorkflow.com Name ___________________________________ 15. Computer Experience/Access Please describe any computer skills/experience/training you have: a. Do you have access to the Internet? Yes No b. Do you have an e-mail address? Yes No c. Can you send and receive e-mail? Yes No d. Are you proficient in any of the following computer programs: i. Yes No ii. Microsoft Works Yes No iii. Microsoft Word Yes No iv. e. Microsoft Excel Microsoft Money Yes No Yes No Are you proficient in any computer programs other than those named above? If yes, please identify those programs in which you are proficient: 16. For any volunteer activities or hobbies in which you have participated, provide the following information: Activity/Organization Years of Involvement Describe Your Activities 17. Have you been involved in any non-work activities in which you have had a leadership position, such as club president, committee chairperson, etc.? Yes No If yes, please provide the following information (please attach additional pages if necessary): Activity/Organization 18. Have you served in the U.S. military? Years of Involvement Yes Branch _____________________________________________ Describe your activities No Dates _______________________________________ Specialized training _______________________________________________________________________________________ If you were in the Army, list your Military Occupational Specialty (MOS) code; for the Air Force list your Air Force Specialty Code (AFSC); for the Navy, Marine Corps or Coast Guard, list your rank and type of discharge: _________________________________ 2 American LegalNet, Inc. www.FormsWorkflow.com SECTION 3 – EMPLOYMENT EXPERIENCE 19. List in chronological order each and every job you have had since age 18, including any periods of self-employment, and provide the information requested. In addition, you are to complete one “Job Detail Form” for each job you list. If you have had more than five (5) jobs since age 18, please list the additional jobs on another sheet of paper. You may photocopy the Job Detail Form so that you have one form for each job you list. Employer Address if known or City & State Type of Business Job Title(s) Dates of Employment to 1. to 2. to 3. to 4. to 5. Please list additional employers on another sheet of paper. 20. Union Employment. Do you now or have you ever worked through or out of a union hall? Yes No If yes, please provide the following information (please attach additional pages if necessary): Union Name Local Number Address if known or City & State The above information, including any attachments, is true to the best of my knowledge. I understand that the information disclosed in this questionnaire may be used by the magistrate in determining my entitlement to workers’ compensation benefits. Signature of Claimant ____________________________________________ Date ________________________________ (Claimant must sign) Claimant’s Name _______________________________________________ (Printed or typed) IF YOU HAVE ATTACHED ANY ADDITIONAL PAGES, PLEASE INCLUDE YOUR FULL NAME AND THE LAST FOUR DIGITS OF YOUR SOCIAL SECURITY NUMBER ON EACH ADDITIONAL PAGE. Completed forms should be exchanged among all parties and not sent to the Workers’ Compensation Agency. DLEG is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-105A (8/08) Authority: Completion: Penalty: 418.205, 418.221, R408.40b(2) Voluntary None www.michigan.gov/wca 3 American LegalNet, Inc. www.FormsWorkflow.com JOB DETAIL FORM Please complete one Job Detail Form for each job listed in Section 3, question 19. JOB # __________________ Employer’s Name (include any self-employment) Employer’s Street Address City State ZIP Code Dates of Employment Rate of Pay $ _______________ per Hour Day Hours per day ____________________________ Week Month Year Days per week _______________________________ Describe this job. In this job, how many total hours each day did you: Walk ________ Stand ________ Sit ________ Climb ________ Reach ________ Stoop (Bend down & forward at waist) ________ Crawl (Move on hands & knees) ________ Kneel (Bend legs to rest on knees) ________ Handle, grab or grasp big objects ________ Crouch (Bend legs & back down & forward) ________ Write, type or handle small objects ________ Lifting and Carrying. Explain what you lifted, how far you carried it, and how often you did this. Check the heaviest weight lifted: Less than 10 lbs. 10 lbs. 20 lbs. 50 lbs. 100 lbs. or more Other __________ Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.) Less than 10 lbs. 10 lbs. 25 lbs. 50 lbs. or more Did this job require you to work with the public? Other __________ Yes No Yes No Yes No Yes No Yes No If yes, describe: Did this job require you to use machines, tools or equipment? If yes, describe: Did this job require you to use technical knowledge or skills? If yes, describe: Did this job require you to perform any duties such as writing, completing reports, etc.? If yes, describe: Did this job require you to supervise other people? If yes, describe: Signature of Claimant ____________________________________________ Date ________________________________ (Claimant must sign) Claimant’s Name _____________________________________ (Printed or typed) Social security number XXX-XX-_______________ (last 4 digits) WC-105A (8/08) American LegalNet, Inc. www.FormsWorkflow.com