OCCUPATIONAL DISEASE & 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 Employer’s business name Your job title Employer’s address Employer’s phone number Employment Dates: From (mo/yr) To (mo/yr) 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 State City ZIP+4 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: Employer’s business name Your job title Employer’s address Employer’s phone number Employment Dates: From (mo/yr) To (mo/yr) 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 State City ZIP+4 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: Employer’s business name Your job title Employer’s address Employer’s phone number Employment Dates: From (mo/yr) To (mo/yr) 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 State City ZIP+4 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: Employer’s business name Your job title Employer’s address Employer’s phone number Employment Dates: From (mo/yr) To (mo/yr) 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 State City ZIP+4 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 PO Box 44291 Olympia WA 98504-4291 I certify that the information is true and correct to the best of my knowledge. Date: F242-071-111 occupational disease work history continuation 10-05 Signature: American LegalNet, Inc. www.USCourtForms.com