Fill and Sign the Interrogatories Compensation Form

                                         SS # NEW JERSEY DEPARTMENT OF LABOR DIVISION OF WORKERS' COMPENSATION CLAIM PETITION NUMBER OCCUPATIONAL INTERROGATORIES Petitioner, VS. Respondent. TO : . Interrogatories within forty-rive (45) days after service. As per Rule 12:235-5.6(e), petitioner demands that respondent answer the within Attorneys for Petitioner BY: A Member of the Firm DATED: PLEASE TAKE NOTICE that the petitioner demands answers, under oath, of the respondent to the following Interrogatories within the time prescribed by the Rules of the Division of Workers' Compensation. I . Set forth the date on which the petitioner started working for the respondent, and the date on which the petitioner last worked for the respondent. What was the chemical composition of the various liquids, powders, gases, fumes, mists, - 2. dust and all other substances and materials which the petitioner used or was exposed to in his/her work or which in the course of his/her employment were handled by petitioner, or which were in anyway used or processed in the vicinity in which the petitioner worked; list these substances both by common or trade name and by chemical name and composition. In the area where the petitioner worked, was there any oven or machinery which in the 3. operation or use thereof generated heat? If the answer is in the affirmative, then specify in particular, the type of oven, machinery and contrivance used and to what degree of temperature of heat such contrivance generated and the purpose for which they were used and the manner in which they were used. (a ) Were smoke, fumes, or dusts emitted from the aforesaid oven, machinery or contrivance while in operation? (b) Describe the type of smoke, fumes, or dusts. (c ) During what period of time was petitioner exposed to such smoke, fumes, or dusts? 4. Describe the room or rooms in which petitioner performed his/her work. Also set forth the size of said room or rooms by length, width and height. Did the rooms in which petitioner did his/her work contain any ventilating or blower 5. systems, and, if so, describe such systems in detail, indicating the location of the intakes and exhausts of such systems and the details of the capacity of such system. 6. If natural ventilation was relied on, state the location and size of all openings. 7. State name and address of all treating physicians who have examined and/or treated the petitioner on behalf of the respondent prior, during and since the time of his/her employment, and give the complete medical findings and diagnosis including other laboratory data of each such physician, and describe in detail the nature of the treatments and dates of treatment. State the interpretation made of any X-rays taken of the petitioner by any physician on 8. behalf of the respondent, naming the particular physician in each instance, and the date of each such X-ray and interpretation made of said X-ray.      Did the respondent prior, during, and subsequent to the period of petitioner's9. employment, cause to be made any air sampling tests to determine the presence and nature of any gases, smoke, fumes, mists and dusts in the environment in which petitioner worked? If the answer to the foregoing is in the affirmative, give in detail the results of said tests, setting forth the dates on which they were performed and by whom made. 10 . Set forth the specific work classifications assigned to the petitioner during his/her employment with the respondent and include the following information: a. The dates of the period covering the various classifications. b. The exact nature of the work performed in such classification and the methods of operations by which such work was performed. 11. Set forth by trade name and chemical composition all substances and materials used in composing molds used in metal pouring. 12. Set forth by trade name and give the chemical composition of all oils, greases, parting compounds, lining compounds or dusting compounds used in lining molds and cores. 13 . Kindly provide the names of all individuals who worked in the immediate vicinity of thepetitioner. 14 . Please list the names of the immediate supervisors under whom the petitioner worked. State whether during the petitioner's employment with respondent, petitioner came into 15. contact with or used asbestos or asbestos products. If the answer to this question is yes, state with particularity the nature of the asbestos or asbestos product, the name of the company who supplied the asbestos, as well as the manufacturer of the asbestos or asbestos product. 16. Attach hereto and make a part of these interrogatories the complete medical file of the petitioner. .CERTIFICATION IN LIEU OF OATH OR AFFIDAVIT I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment for contempt of court.