U.S. Depart ment of La bor Office of Administrative Law Judges John W. McCormack Post Office and Courthouse Room 505 Boston, MA 02109 (617) 223-9355 (617) 223-4254 (FAX) Case Caption and OALJ No.: PRETRIAL S TATEMENT o f: Claimant Director, OWCP Respondent 1. Briefly summarize, below or on attached sheet, the facts or circumstances you contend gave rise to this claim, and describe the nature of the claimed injury or disease. 2. State your intentions as to the place of injury ; its date ; the date disability commenced ; the date claimant became aware disability was work related ; and the date employer had notice of the injury . 3. This claim is for: compensation; medical benefits; penalties (under ); other . 4. Do you contend or concede that: (a) The L HWCA applies to this claim. Yes No (b) At the time of the alleged injury, an employer-employee relationship existed between Claimant and Employer. Yes No (c) Claimant has suffered an injury or disease. Yes No (d) The alleged injury or disease arose out of an in the course of claimants employment. Yes No (e) The claim was timely noticed; untimely noticed; timely filed; untimely filed. (f) Claimant is/was entitled to compensation Yes No; medical benefits Yes No (g) Employer/Carrier is currently providing: compensation Yes No medical benefits Yes No (h) Claimant has reached maximum medical improvement. No Yes, on (i) Claimant has outstanding medical bills. No; Yes to: $ $ $ $ $ $ American LegalNet, Inc. www.USCourtForms.com>>>> 25. Are nature and extent of disability disputed? Yes No 6. Is Claimant now working? NoYes in his usual employment started on in alternate employment started on 7. You contend or concede that claimant is now able to do: his regular pre-injury work without loss of earnings; alternative work; no work. 8. You contend or concede that the alleged injury or disease is unscheduled; is a scheduled injury which caused a % loss/loss of use of the injury caused disability which was/is: permanent total from to temporary total from to permanent partial from to temporary partial from to 9. You contend or conc ede that Claim ants average w eekly wa ge wh en injured wa s $ under 10 subsection , and tha t his retaine d weekly ea rning ca pacity is: zero; or $ based on his current earnings; labor market survey(s); or other facts 10. Is Special Fund relief sought? No; Yes If Yes, is the Director conceding entitlement; asserting absolute bar; or denying entitlement on the grounds of no pre-existing disability; disability not manifest to employer; contribution requirement not met 11. Set forth below or on separate page(s) other contentions, issues or ultimate facts which you will present at trial (e.g. last responsible employer; 33(g); collateral estoppel; credits; etc.), and succinctl y brief any novel legal questions.12. Witnesses you intend to have testify at the hearing. 13. Estimated total trial time: days hours DATE: /s/ Counsel For -2- American LegalNet, Inc. www.USCourtForms.com