Workers Comp
Intake Form
LET'S GET STARTED!
Full Name *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Mailing Address *
Your answer
Birthdate *
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What Federal Agency do you work for? *
Your answer
What is your job title? *
Your answer
What type of injury did you experience? *
Your answer
How were you injured? *
Your answer
Date of Injury *
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DD
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YYYY
Were you given a diagnosis by a physician? If so, what?
Your answer
Did you file a report? *
How did you file the report? (Written - which form? or Verbal - to whom and when was it reported?) *
Your answer
If yes, was your claim accepted? *
Your answer
If applicable, who were the witnesses to the injury? *
If not applicable, type NA
Your answer
What was the response of your supervisor? *
Your answer
When and where were you initially treated? *
Your answer
What type of health provider administered this treatment? *
Example: Nurse Practitioner, Doctor, Specialist, Psychiatrist, etc.
Your answer
Was there follow up treatment? *
Your answer
What type of treatments were administered? *
Your answer
What was the result of the treatments? *
Your answer
Are you still dealing with your injury? If so, in what way? *
Your answer
What is your current prognosis according to your physician? *
Your answer
If you disagree with your physician, what do you believe your prognosis is? *
Your answer
How has your job performance been since you've been injured? *
Your answer
What is your current status with your employer? Select all that apply. *
Have you filed an EEO, MSPB, or Grievance case against your employer? *
What is your current status with OWCP? *
Your answer
Have you been awarded compensation? If yes, since when? *
Your answer
Were you denied compensation? If yes, when? What was the stated reason for the denial? *
Your answer
Have you filed an appeal? If yes, what type of appeal and what was your argument? *
Your answer
What results do you want us to help you achieve? *
Your answer
Additional Comments
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