Fill and Sign the Nj Occupational Interrogatories Form

                                   NEW JERSEY DEPARTMENT OF LABOR DIVISION OF WORKERS' COMPENSATION CLAIM PETITION NUMBER: SS#: ) ) Petitioner, ) VS . ) OCCUPATIONAL INTERROGATORIES ) Respondent. ) ) SIR: As per Rule 12:235-5.6(e), respondent demands that petitioner answer the within Interrogatories within forty-five (45) days after service. ATTORNEYS FOR RESPONDENT BY : A MEMBER OF THE FIRM DATED: PLEASE TAKE NOTICE that the respondent demands answers, under oath, of the petitioner to the following interrogatories within the time prescribed by the rules of the Division of Workers' Compensation. I . Set forth in detail the specific occupational disease or condition which petitioner claims was caused, aggravated or contributed to by employment with the respondent. 2. Set forth the period of employment and the dates of the alleged exposure. 3. Set forth the nature of the exposure that allegedly caused the occupational injury in question. If exposure to fumes is alleged, set forth quantitative evidence of the level and 4. duration of the alleged exposure, the component elements of same and how said exposure is in excess of that ordinarily encountered in everyday living. If the occupational injury claimed resulted from repetitive motion, set forth in detail 5. the nature of the activity, the parts of the body affected and the duration said activity was performed on a daily basis. If the claimed occupational disease resulted from repetitive bending and lifting, set forth 6. in detail on a daily basis the matter lifted, its weight; whether the object was carried; the amount of time engaged in such activity on a daily basis and whether such activity exceeded that normally experienced in everyday living. 7. If an occupational hearing loss is alleged, please describe the duration of any exposure to noise on a daily basis and identify the machinery or equipment from which it emanated. If an occupational cardiovascular or cerebrovascular condition is alleged, state in detail 8. the intensity and duration of the work effort that allegedly precipitated the condition and the manner in which same was qualitatively more intense than the physical activity to which petitioner was accustomed to outside of work. a. Please state the time interval between the alleged precipitating work effort and the evidence of dysfunction. b. Provide a description of the activity engaged in by petitioner outside of work. If an occupational psychiatric condition is alleged, please state in detail the nature and 9. duration of any stressful working condition, the source, and how said condition(s) were unreasonable and peculiar to the work place. 10. Set forth the date and circumstances under which the petitioner became aware that the claimed injuries resulted from his employment. 11. Set forth the specific machinery, equipment, condition, or circumstances which caused or contributed to the claimed occupational diseases. a. State in detail the medical basis for concluding that the occupational disease(s) are causally related to the alleged exposure. 12 Set forth the date and circumstances under which respondent had actual notice and knowledge of petitioner's occupational injury, and the names and titles of respondent's personnel having such knowledge. a. If petitioner alleges that such knowledge resulted from environmental testing, set forth the identity of the person or institution performing the test, the date, the nature of same, and attach copies of their report(s). Set forth chronologically the names and addresses of all medical providers an 13. institutions, the dates, the nature of such treatment and the diagnosis; annexing copies of treating records for the conditions alleged. a. State whether any of the medical treatment was authorized by the respondent; the identity of the person providing said authorization and the date and nature of same. b. If the petitioner is claiming that respondent is liable for the payment of any medical bills incurred, please list same and provide copies. 14. If temporary total disability benefits are being claimed in connection with any of the alleged occupational disease(s), please identify the specific period of time lost, and the medical justification for remaining out of work - annexing copies of any supporting medical reports. Identify all subsequent employers by name and address; the nature of said employment; 15. the duration of said employment; the specific activity performed by petitioner; a specific description of the work environment. If any subsequent employers identified required a pre-employment medical a. examination, set forth the date of such examination and the name and address of the physician performing same. If it is alleged that the occupational diseases claimed resulted from exposure to asbestos 16. or asbestos-containing material, please state in detail chronologically each and every employment, including the names and addresses of the employer, the type of product manufactured, the period of employment and the nature of the work performed by petitioner. a. Set forth chronologically the names and addresses of any and all persons or institutions and the dates that petitioner underwent a chest X-ray.      If an occupational pulmonary condition is alleged, set forth in detail petitioner's 17. complete smoking history, specifying the form of tobacco smoked, the quantity per day and the duration of tobacco consumption. 18. State in detail whether petitioner has ever received any money for any injuries in the past or whether petitioner is currently prosecuting a civil action or any other workers' compensation claim at the present time, for injuries or conditions alleged in this matter. If so, please state the names of the defendants or respondents; the Court in which the matter was or is pending; the identity of the attorney pursuing said matter on behalf of the petitioner; the amount of any settlements or awards; the date of the accident or injury; and the nature of the injuries claimed. If it is alleged that the occupational exposures aggravated, accelerated, or exacerbated 19. a pre-existing medical condition, identify the nature of said condition with specificity, the dates and nature of any and all medical treatment provided; the identity of any and all providers by name and address, and the medical diagnoses. 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.