F242-071-000 Occupational Disease Work History 10-2005 Department of Labor and Industries Claims Section PO Box 44291 Olympia WA 98504-4291 Occupational Disease & Employment History Name Claim Number Occupational Disease History What is the medical condition for which you are filing this claim? What symptoms do you have? When did you first notice you had these symptoms? Month / Year When were you first told by a doctor that your symptoms were caused by your job? Month / Year Have you ever seen any other doctor for these symptoms? Yes No Have you ever had any medical tests for these symptoms? Yes No Name of doctor who told you that your symptoms are related to your job: (print or type) Address City State ZIP+4 Please complete the attached medical records release forms so that we can obtain your records. If the release is not completed, your claim for benefits will be delayed or may be rejected. Is your completed release attached? Yes No Type of work you perform that you believe caused your symptoms: Start date of employment at the first job you think caused your symptoms. Month / Year What activity did you perform at work that you believe caused your symptoms? (Please check all that apply) Gripping or Pinching Pulling Kneeling Tools used Forceful activity Pushing Reaching overhead Twisting with my Repetitive tasks (describe) Other (describe) Employment History Please start with your most RECENT job and work BACKWARDS Include all current and past employment. All dates should be your best estimate. You must list any breaks or interruptions in your work history. Employer222s business name Your job title Employment Dates: From (mo/yr) To (mo/yr) Employer222s address Employer222s phone number City State ZIP+4 How many hours per week did you perform the activity you believe caused your symptoms? hours Describe the job duties, tool use or repetitive activities done on a regular basis. Include approximately how much time per day you spent doing each activity Indicate any break or interruption in your work history during this job or between this job and the next. From (mo/yr) To (mo/yr) Reason for interruption: Employer222s business name Your job title Employment Dates: From (mo/yr) To (mo/yr) Employer222s address Employer222s phone number City State ZIP+4 How many hours per week did you perform the activity you believe caused your symptoms? hours Describe the job duties, tool use or repetitive activities done on a regular basis. Include approximately how much time per day you spent doing each activity Indicate any break or interruption in your work history during this job or between this job and the next. From (mo/yr) To (mo/yr) Reason for interruption: I certify that the information is true and correct to the best of my knowledge. Page 1 of Date: Signature: American LegalNet, Inc. www.FormsWorkFlow.com F242-071- Occupational Disease Work History Continuation 10-2005 Occupational Disease and Employment History (Continuation) Page of Name (please print) Claim Number This is a continuation sheet. You must complete the first page of this form. If additional space is needed you may make copies of this form. Please continue with your most Recent job and work Backwards Employer222s business name Your job title Employment Dates: From (mo/yr) To (mo/yr) Employer222s address Employer222s phone number City State ZIP+4 How many hours per week did you perform the activity you believe caused your symptoms? hours Describe the job duties, tool use or repetitive activities done on a regular basis. Include approximately how much time per day you spent doing each activity Indicate any break or interruption in your work history during this job or between this job and the next. From (mo/yr) To (mo/yr) Reason for interruption: Employer222s business name Your job title Employment Dates: From (mo/yr) To (mo/yr) Employer222s address Employer222s phone number City State ZIP+4 How many hours per week did you perform the activity you believe caused your symptoms? hours Describe the job duties, tool use or repetitive activities done on a regular basis. Include approximately how much time per day you spent doing each activity Indicate any break or interruption in your work history during this job or between this job and the next. From (mo/yr) To (mo/yr) Reason for interruption: Employer222s business name Your job title Employment Dates: From (mo/yr) To (mo/yr) Employer222s address Employer222s phone number City State ZIP+4 How many hours per week did you perform the activity you believe caused your symptoms? hours Describe the job duties, tool use or repetitive activities done on a regular basis. Include approximately how much time per day you spent doing each activity Indicate any break or interruption in your work history during this job or between this job and the next. From (mo/yr) To (mo/yr) Reason for interruption: Employer222s business name Your job title Employment Dates: From (mo/yr) To (mo/yr) Employer222s address Employer222s phone number City State ZIP+4 How many hours per week did you perform the activity you believe caused your symptoms? hours Describe the job duties, tool use or repetitive activities done on a regular basis. Include approximately how much time per day you spent doing each activity Indicate any break or interruption in your work history during this job or between this job and the next. From (mo/yr) To (mo/yr) Reason for interruption: Dept of Labor and Industries I certify that the information is true and correct to the best of my knowledge. PO Box 44291 Olympia WA 98504-4291 Date: Signature: American LegalNet, Inc. www.FormsWorkFlow.com