Fill and Sign the Occupational Disease Work Form

                                                                Page                                                                                                                                                                                                                                      ( ) ( ) ( ) ( ) ( ) / / OCCUPATIONAL DISEASE WORK HISTORY (CONTINUATION) of Name Claim Number (This is a continuation sheet, must complete original form first.) Please CONTINUE with your most RECENT job and work BACKWARDS. Employer's business name Employment From (mo/yr) To (mo/yr) dates: Employer's address Employer's phone number City State ZIP+4 Indicate time exposed to noise, repetitive motion or chemicals in hours per week . Hours: Describe the job duties and type of equipment or tools used or operated. Employer's business name Employment From (mo/yr) To (mo/yr) dates: Employer's address Employer's phone number City State ZIP+4 Indicate time exposed to noise, repetitive motion or chemicals in hours per week . Hours: Describe the job duties and type of equipment or tools used or operated. Employer's business name Employment From (mo/yr) To (mo/yr) dates: Employer's address Employer's phone number City State ZIP+4 Indicate time exposed to noise, repetitive motion or chemicals in hours per week . Hours: Describe the job duties and type of equipment or tools used or operated. Employer's business name Employment From (mo/yr) To (mo/yr) dates: Employer's address Employer's phone number City State ZIP+4 Indicate time exposed to noise, repetitive motion or chemicals in hours per week . Hours: Describe the job duties and type of equipment or tools used or operated. Employer's business name Employment From (mo/yr) To (mo/yr) dates: Employer's address Employer's phone number City State ZIP+4 Indicate time exposed to noise, repetitive motion or chemicals in hours per week . Hours: Describe the job duties and type of equipment or tools used or operated. Dept of Labor & Industries I certify that the information is true and correct to the best of my knowledge. PO Box 44291Olympia WA 98504- 4291 Date: Signature: F242-071-111 (PDF) occupational disease work history (continuation) 5-00