HEARING AND NOISE QUESTIONNAIRE CLAIMS DIVISION SFN 51698 (08/2014) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com Injured Worker's Name Claim Number Mailing Date PAGE 1 DIRECTIONS: PLEASE PRINT OR TYPE USING BLACK OR BLUE INK. Read and answer each question. If additional space is needed to respond, use the back of these pages or a separate sheet of paper. Please be sure to sign and date the last page and return this questionnaire to Workforce Safety & Insurance at the address listed above within 14 days from the mailing date listed above. Injured workers are subject to penalty for failure to comply or for any false statement. Yes No 1. Have you ever had hearing trouble? If yes, describe: 2. Do you now have hearing trouble? If yes, describe: Yes No 3. When did you first realize you could not hear well? 4. Was the hearing problem of sudden or gradual onset? 5. Has anyone ever suggested that you have hearing trouble? If yes, by who and when: Yes No 6. Have you ever had an audiogram (hearing test) performed on you? If yes, when and where: Yes No 7. How long has it been since your most recent exposure to noise? What was the noise from? 8. 9. Do you work in a noisy area? Yes No Yes No Do you wear any kind of hearing protection in your work area? If yes, what type do you use? (i.e. muff, ear plugs) 10. How long have you used this hearing protection? 11. 12. Do you wear the hearing protection all the time? Yes No Yes No Does your hearing improve when you are away from the job? Overnight? Yes No Days off? Yes No American LegalNet, Inc. www.FormsWorkFlow.com C129 HEARING AND NOISE QUESTIONNAIRE (con't) Claim Number Injured Worker PAGE 2 OF 4 13. Do you have a second job? If yes, what and where: Yes No Length of employment: 14. Prior to your current employment, have you ever worked in a noisy industry where you had to raise your voice? Yes No If yes, for how long? What was the job? Who was your employer? When did you work for them? 15. Were you in the military service? If yes, give dates of service: Yes No 16. What type of gunfire were you exposed to? (artillery, small arms, other) 17. Have you been exposed to loud noises off the job? (Hunting, motorcycles, snowmobiles, hard rock music, etc.) Yes No If yes, describe: 18. 19. Do you swim or scuba dive? Yes No What type of shooting sports do you participate in? (Hunting, target, skeet, trap, other) 20. Have you ever been exposed to blasting or other explosive noises? If yes, describe: Yes No 21. Have you ever been struck on the head or neck? If yes, describe: Yes No 22. Have you ever suffered a head injury with unconsciousness? If yes, when? Yes No Describe: 23. Have you ever had diabetes? If yes, how long? Yes No American LegalNet, Inc. www.FormsWorkFlow.com C129 HEARING AND NOISE QUESTIONNAIRE (con't) Claim Number Injured Worker PAGE 3 OF 4 24. Have you ever suffered from periods of dizziness or loss of balance? If yes, when and how long did each episode last? Yes No 25. Have you ever had ear trouble as a child or adult? If yes, when? Yes No 26. Have you ever had ear drainage? If yes, when? Yes No 27. Have you ever punctured/perforated your eardrums? If yes, when? Yes No 28. Have you ever had ear surgery? If yes, why? Yes No When? 29. Have you ever had ear or head noises? If yes, describe: Yes No 30. Have you ever had ear infections? If yes, describe: Yes No 31. Have you ever had mumps, measles, scarlet fever, or other high fevers? If yes, which? Yes No When? 32. 33. 34. Do you have recurring headaches? Do you have difficulty hearing at times? Yes Yes No No Have you gone to a doctor for hearing problems? Yes No If yes, list dates, names, addresses of doctors, their findings, their treatments, and results of hearing test: 35. Are you presently under medical care by a doctor? If yes, for what condition? Yes No Name of doctor? 36. What kind of medications do you now take (or have taken) for medical treatment? American LegalNet, Inc. www.FormsWorkFlow.com C129 HEARING AND NOISE QUESTIONNAIRE (con't) Claim Number Injured Worker PAGE 4 OF 4 37. Have any members of your family ever suffered any hearing loss? If yes, what caused the hearing loss? Yes No 38. Do you wear a hearing aid? Yes If yes, how long have you had it? No 39. 40. Does the hearing aid help your hearing ability? Describe your hearing ability in your own words: Yes No 41. Injured worker's remarks: UPON COMPLETION OF THIS FORM, PLEASE SIGN, DATE, AND RETURN IT TO: Attn Claims Department Workforce Safety & Insurance PO Box 5585 Bismarck, ND 58506-5585 FRAUD WARNING � PENALTY FOR FILING FALSE CLAIMS WITH WORKFORCE SAFETY & INSURANCE (WSI) Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the receipt of income or an increase in income from employment in connection with any claim or application for workers compensation benefits will FORFEIT ANY FUTURE BENEFITS and may be GUILTY OF A FELONY which is punishable by IMPRISONMENT, SUBSTANTIAL FINES, OR BOTH. These criminal penalties are applicable to ALL PERSONS dealing with the Fund, including INJURED WORKERS, EMPLOYERS, MEDICAL PROVIDERS, AND ATTORNEYS. I ACKNOWLEDGE, by my signature on this form, THAT I HAVE READ AND UNDERSTAND THE ABOVE DESCRIPTION OF THE PENALTIES FOR SUBMITTING A FALSE CLAIM FOR BENEFITS OR MAKING FALSE STATEMENTS TO WSI. I understand that NDWC is relying upon the truth of my statements in awarding benefits or providing services on this claim. I CERTIFY THAT I HAVE NOT FILED A FALSE CLAIM, NOR MADE ANY FALSE STATEMENT, NOR KNOW OF ANY FALSE STATEMENT MADE IN CONNECTION WITH THIS CLAIM FOR BENEFITS WITH WSI. Injured Worker's Signature Date American LegalNet, Inc. www.FormsWorkFlow.com C129