Fill and Sign the Mississippi Plaintiffs First Set of Interrogatories and Request Form

BEFORE THE MISSISSIPPI WORKERS' COMPENSATION COMISSION **** CLAIMANT VS. MWCC NO. 91 12646-E-6979 **** EMPLOYEE CLAIMANT'S ANSWERS TO EMPLOYER'S FIRST SET OF INTERROGATORIES TO CLAIMANT, AND CLAIMANT'S RESPONSES TO EMPLOYER'S FIRST SET OF REQUESTS FOR PRODUCTION OF DOCUMENTS TO CLAIMANT COMES NOW the Claimant, ****, by and through her attorney, ****, and files this her Answers to Employer's First Set of Interrogatories and Responses to Employer's First Set of Requests for Production of Documents to Claimant, to wit: 1. Please state your full legal name, and your Social Security number. RESPONSE: ****. 2. Please state any other names or aliases by which you have been known and the inclusive dates during which you were known by each such name. RESPONSE: **** (married name) from 1979-1983. 3. Please state each residence address you have had during the immediately preceding ten years, including your present residence address, and the inclusive dates you have lived at each such address. RESPONSE: My present address is ****. I have lived here from about 1983 to the present time. ****. 5. Please describe your educational background including highest grade completed and/or date passed a high school equivalency examination, if applicable. RESPONSE: I went to the eighth grade in school, then got my GED in about 1986. I also received a American College Nursing Assistant Certificate in about 1988. 6. Please describe all vocational or occupational training programs in which you have been involved. RESPONSE: I completed DCW (Direct Care Worker) Certificate in May, 1990. 7. Please describe your driving record, such description to include your driver's license number, state(s) in which issued, whether regular or commercial, any restrictions you have on same, whether such has ever been suspended and if so, the reason and dates for each such suspension. RESPONSE: Mississippi driver's license regular, one restriction - glasses, no suspensions. 8. Please identify all sporting activities in which you have engaged and the inclusive dates of your participation in those activities. RESPONSE: I participated in bowling from about age 16 until my accident. I also used to fish, play softball, bicycle, and skate until my accident. 9. Please describe your employment history, including military service, prior to your accident herein, such description to include, as to each employment relationship, the name and address of each such employer, the dates of each such employment, the type of work performed by you while so employed, and the reason for termination of such employment. RESPONSE: In 1976-1977, I worked at the ****, In 1977-1978, I worked at ****, and did dry cleaning and washing. In 1979-1980, I worked at ****, and worked slip table, pulling lumber and putting on table. In 1980 - 1988, I worked at a bar called **** as a waitress for about six months. Then I went back to school to get my GED and worked part-time babysitting. In 1987-1988, I worked at **** as a nursing assistant. I left to have a baby. In May through October of 1988, I worked at ****as a nursing assistant. I changed jobs for more pay. In 1990-1991, I worked at ****, at night-time, cleaning offices. After the accident at ****, I was unable to the work at this job. 10. Please describe fully the accident(s) which subject matter of this claim, such description to include precise date, time, and location of said accident(s), the activities in which you were engaged at the time of the accident(s), and a description of how the accident(s) occurred. RESPONSE: A patient at **** pushed me against a door, slamming my right hand in the door, clawing at my face, and pulled me to the floor cutting the back of my hand and I landed on my elbow. 11. Please list the names and addresses of the persons known is the RESPONSE: ****. 12. Please state the name and address of the person to whom you gave notice of your alleged accident(s), the date, time and place wherein such notice was given, and state exactly what you told said person regarding your alleged accident(s). RESPONSE: I showed **** my hand about 11:45 a.m. on July 30, 1991. 13. Please describe the nature of the medical condition for which you are making claim herein, such description to include the part(s) of your body involved. RESPONSE: I have ligamentous injuries to my right upper extremity that have required proximal row carpectomy. 14. Please identify by name and address each doctor, physician, surgeon, psychologist, or other medical practitioner who has examined and/or treated you for your alleged injuries or medical condition for which claim is being made herein. RESPONSE: ****. 15. Please list the name and address of the hospital(s), if any, in which you were a patient for the medical condition(s) for which claim is being made herein, and state the particular dates during which you were a patient therein. RESPONSE: **** in December 23, 1991 to about January 27, 1992. 16. Please describe your employment history since the accident(s) which is the subject matter of this claim, such description to include the name and address of each employer for 17. In the event you received medical treatment to your right upper extremity, right shoulder, and back before July 30, 1991, please describe such medical treatment to include the date of such treatment, the nature of the injury or medical condition for which treatment was received, and the name and address or each doctor or other medical practitioner who examined and/or treated you there for. RESPONSE: No. 18. In the event you received psychological or psychiatric testing, evaluation, or treatment before July 30, 1991, please describe such medical treatment to include the date of such treatment, the nature of the injury or medical condition for which treatment was received, and the name and address of each doctor or other medical practitioner who examined and/or treated you there for. RESPONSE: No. 19. Other than the accident(s) which is the subject matter of this claim, please describe any other accidents you have had involving injuries to any part of your body whatsoever, such description to include the date(s) of each such injury, the part(s) of your body involved, and the name and address of each doctor or other medical practitioner who examined and/or treated you there for. RESPONSE: I don't know of any. 20. If you have filed any suit or made any claim, formally or informally, for damages or any sum of money whatsoever against any parties other than the defendants in this workers' compensation case, please state the name and address of the party or parties against whom such suit was filed or claim made, and if pending in Court, give the name of the Court wherein the action is pending, description to include the name and address of each doctor or other medical practitioner seen by you, and the nature of the medical problem for which such treatment or examination was received. RESPONSE: I have not had any medical treatment in the ten years before my accident. 22. Please describe all medical treatment and/or medical examinations you have received since the accident(s) which is the subject matter of this claim for medical problems other than those for which claim is being made herein, such description to include the name and address of each doctor or other medical practitioner seen by you, and the nature of the medical problem for which such treatment or examination was received. RESPONSE: I have had surgery twice, therapy, and medications, x-rays, by ****. 23. If you have ever pled guilty to or been convicted of a crime (excluding minor traffic offenses), please state, with reference to each such conviction or guilty plea, the nature of the crime and the date of the conviction/guilty plea. RESPONSE: No. 24. Please state the name and address of each and every lay witness you intend to call as a witness in this cause. RESPONSE: Myself. 25. Please state the name and address of each and every expert witness, including medical experts, you intend to call as a witness in this cause, and state the substance of the facts and opinions to which each such expert is expected to testify and a summary of the grounds for each opinion. RESPONSE: ****, my treating physician, **** will testify via probability, the accident of July 29, 1991, caused the injury to my right upper extremity. He will further testify that he assigned me a thirty percent (30%) medical impairment rating and prescribed restrictions as to future employment. 26. If you have filed a claim for unemployment compensation benefits since the date of the alleged accident(s) in this case please identify the inclusive dates during which you have received such benefits. RESPONSE: I filed after reaching MMI but was denied benefits as I am being carried as on leave without pay by defendant herein. CLAIMANT'S RESPONSES TO EMPLOYER'S FIRST SET OF REQUESTS FOR PRODUCTION OF DOCUMENTS TO CLAIMANT 1. Please produce copies of any and all medical reports and records in your possession, care, custody or control, concerning any examinations or treatments received by you as a result of the injuries/medical conditions, for which claim is being made herein. RESPONSE: See medical reports of **** in possession of defendant and on file with the Commission. 2. Please produce a copy of each and every medical, hospital, drug, and doctor's bill in your possession, care, custody or control, incurred by you in connection with the injuries/medical conditions for which claim is being made herein. RESPONSE: Will supplement. 3. Please produce copies of any and all medical reports and records in your possession, care, custody or control, concerning any examinations or treatments received by you for any medical conditions other than those for which claim is being made herein. includes the gross wages paid to you during each week of such employment and the number of days worked per week for each such payment. RESPONSE: None. 5. In the event you have filed any reports or tax returns with the Internal Revenue Service or the Mississippi State Tax Commission since the accident which is the subject matter of this claim, please produce copies of all such forms, reports or schedules. RESPONSE: None in my possession. 6. Please provide to the employer an authorization form signed by you authorizing the employer and its agents and attorneys permission to obtain any and all medical records, medical reports, x-rays, x-ray reports laboratory reports, nurses' notes, physicians' orders, and any and all other documents relating to your medical condition, or medical examinations and treatment which you have received from any physician, doctor, hospital, or other provider of medical services. For your convenience, such an authorization form is attached hereto. RESPONSE: See attached authorization. 7. Please provide to the employer an authorization form signed by you authorizing the employer and its agents and attorneys to obtain from each and every employer by whom you have been employed or attempted to obtain employment your wage and employment information. For your convenience, such an authorization form is attached hereto. RESPONSE: See attached authorization. 8. In the event you have applied for or have otherwise made a claim against any private or group hospitalization, medical, or disability insurance regarding the injury which is the subject includes the gross wages paid to you during each week of such employment and the number of days worked per week for each such payment. RESPONSE: None. RESPONSE: B-3, Wage statement, and affidavit of ****, my treating physician, which is currently on file with the Commission. 10. In the event you have ever had a vocational rehabilitation and/or work capacity evaluation conducted regarding yourself, please produce a copy of any documents regarding such which may be in your possession, care, custody or control. RESPONSE: None. 11. Please produce a copy of any and all documents in your possession, care, custody or control relating to any claim which you have filed for Social Security disability benefits. RESPONSE: None. Respectfully submitted, **** STATE OF MISSISSIPPI COUNTY OF HINDS PERSONALLY APPEARED BEFORE ME, the undersigned authority in and for the jurisdiction aforesaid, the within named **** who, after being by me first duly sworn, stated on oath that the matters and things set forth herein are true and correct as therein stated. SWORN TO AND SUBSCRIBED BEFORE ME, this the __ day of November , 1992. My Commission Expires: NOTARY PUBLIC STATE OF MISSISSIPPI AT LARGE MY COMMISSION EXPIRES: Aug.16, 1996. THRU NOTARY PUBLIC UNDERWRITTEN. PREPARED, SUBMITTED BY AND AS TO OBJECTIONS: **** CERTIFICATE OF SERVICE _ I, the undersigned attorney, do hereby certify that have this date mailed by United States mail, postage prepaid, a true and correct copy of the above and foregoing pleading(s) to: *** AUTHORIZATION TO RELEASE MEDICAL INFORMATION I, ****, hereby authorize any doctor, physician, psychologist, hospital, or other provider of medical and related care to release unto my employer, ****, and its third party administrator, ****, their agents, employees, or attorneys, **** copies of all medical reports, psychological test results, opinions, records, x-rays, x-ray reports, laboratory reports, nurses' notes, physicians' orders, and any and all other documents relating to any examination or treatment of myself. I hereby agree that a copy of this authorization form shall have the same force and effect as the original thereof and further agree that this authorization shall remain valid so long as the claim against my above named employer is pending. **** Date: ______ AUTHORIZATION TO RELEASE WAGE AND EMPLOYMENT INFORMATION I, ****, hereby authorize any employer by whom I have been employed or sought employment, any labor Union of which I am or have been a member, the Mississippi Employment Security Commission, or the Social Security Administration, to release unto my employer, ****, and its third party administrator, ****, their agents, employees, or attorneys, ****, any information pertaining to my employment, employment applications, information pertaining to my wages, Social Security Administration records, and other related matters. I hereby agree that a copy of this authorization form shall have the same force and effect as the original thereof. **** Date: