Fill and Sign the State of California Division of Workers Compensation Form

STATE OF CALIFORNIA Division of Workers' Compensation Disability Evaluation Unit EMPLOYEE'S DISABILITY QUESTIONNAIRE Employee DEU Use Only This form will aid the doctor in determining your permanent impairment o\ r disability. Please complete this form and give it to the physician who will be performing the evaluation. The doct\ or will include this form with his or her report and submit it to the Disability Evaluation Unit, with a copy to you and \ your claims administrator. DWC-AD form100 (DEU) Page 1 (REV. 11/2008) MM/DD/YYYY MM/DD/YYYY DWC-AD form100 (DEU) First Name Last Name MI Street Address 2/PO Box (Please leave blank spaces between numbers, nam\ es or words) Street Address 1/PO Box (Please leave blank spaces between numbers, nam\ es or words) International Address (Please leave blank spaces between numbers, names\ or words) Zip Code City Date of Birth Date of Injury SSN (Numbers Only) Employer Nature of Employers Business Claim Number 1 State PLEASE ANSWER THE FOLLOWING QUESTIONS FULLY: How was your evaluating doctor selected? (check one) DWC-AD form100 (DEU) Page 2 (REV. 11/2008) Date MM/DD/YYYY DWC-AD form100 (DEU) ____________________________________________ Signature Claim Number 2 Claim Number 3 Claim Number 4 Claim Number 5 Other From a list of doctors provided by the State of California, Division of \ Workers’ Compensation. (explain) What is the name of the doctor who will be doing the evaluation? What were your job duties at the time of your injury? What is the disability resulting from your injury? How does this injury affect you in your work? Have you ever had a disability as a result of another injury or illness?\ If so, when? Please describe the disability? When is your examination scheduled?