The Commonwealth of Massachusetts
FORM 160
Department of Industrial Accidents
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
Info. Line 800-323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470
http://www.mass.gov/dia
Page 1 of 2
EMPLOYEE BIOGRAPHICAL DATA
PREPARE THIS FORM PRIOR TO A HEARING. THIS FORM IS TO BE GIVEN
TO OPPOSING COUNSEL AND MAY BE OFFERED AS EVIDENCE IF SO TESTIFIED.
Employee
Please Print or Type
1. Employee’s Name (Last, First, MI):
2. Social Security Number*:
3. Home Telephone No.:
4. Number of Dependents:
5. Home Address (No., Street, City, State & Zip Code):
6. Date of Birth:
7. Place of Birth:
8. Date U.S. Domicile Established:
10. Spouses Name:
11. Spouses Occupation:
9. Marital Status:
12. Names and Ages of Children (attach additional sheet if needed):
1.
Age ______
2.
Age_______
3.
Age_______
4.
Age_______
5.
Age_______
6.
Age_______
Education
14. Highest Grade Completed and/or Date of Graduation:
13. Name & Address of Last School Attended:
15. List any Special Skills or Training Received:
Military Service
17. Dates of Service (mm/dd/yyyy):
16. Branch of Service and Rank:
18. Military Occupation or Specialty:
Work History (begin with most recent employment)
19.
A. Employer: ____________________________________ From ______________ To _____________
Job Description: ____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
B. Employer: ____________________________________ From ______________ To _____________
Job Description: ____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Form 160 - Revised 7/2013 - Reproduce as needed.
*Disclosure of Social Security No. is optional. It will aid in processing forms.
(OVER)
The Commonwealth of Massachusetts
FORM 160
Department of Industrial Accidents
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
Info. Line 800-323-3249 ext. 7470 in Mass. Outside Mass. - 617-727-4900 ext. 7470
http://www.mass.gov/dia
Page 1 of 2
EMPLOYEE BIOGRAPHICAL DATA
PREPARE THIS FORM PRIOR TO A HEARING. THIS FORM IS TO BE GIVEN
TO OPPOSING COUNSEL AND MAY BE OFFERED AS EVIDENCE IF SO TESTIFIED.
Employee
Please Print or Type
1. Employee’s Name (Last, First, MI):
2. Social Security Number*:
3. Home Telephone No.:
4. Number of Dependents:
5. Home Address (No., Street, City, State & Zip Code):
6. Date of Birth:
7. Place of Birth:
8. Date U.S. Domicile Established:
10. Spouses Name:
11. Spouses Occupation:
9. Marital Status:
12. Names and Ages of Children (attach additional sheet if needed):
1.
Age ______
2.
Age_______
3.
Age_______
4.
Age_______
5.
Age_______
6.
Age_______
Education
14. Highest Grade Completed and/or Date of Graduation:
13. Name & Address of Last School Attended:
15. List any Special Skills or Training Received:
Military Service
17. Dates of Service (mm/dd/yyyy):
16. Branch of Service and Rank:
18. Military Occupation or Specialty:
Work History (begin with most recent employment)
19.
A. Employer: ____________________________________ From ______________ To _____________
Job Description: ____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
B. Employer: ____________________________________ From ______________ To _____________
Job Description: ____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Form 160 - Revised 7/2013 - Reproduce as needed.
*Disclosure of Social Security No. is optional. It will aid in processing forms.
(OVER)
Page 2 of 2
Work History - Continued
19.
C. Employer: ____________________________________ From - ______________ To _____________
Job Description: ____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
D. Employer: ____________________________________ From - ______________ To _____________
Job Description: ____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
E. Employer: ____________________________________ From - ______________ To _____________
Job Description: ____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Medical Data (related to industrial injury)
20. Date of First Medical Treatment (mm/dd/yyyy):
21. Place of First Medical Treatment:
22. Name(s) of Treating Physicians and Dates of Treatments (in Chronological Order):
a.
Date _____
b.
Date _____
c.
Date _____
d.
Date _____
e.
Date _____
f.
Date _____
23. Date(s) and Location(s) of OUTPATIENT Hospital Treatment:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
24. Date(s) and Location(s) of INPATIENT Hospital Treatment:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
25. List any Hospital Records and/or Physician reports to be Offered in Evidence by Agreement of Counsel (Please Attach):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________