Form 161 "Employee's Hearing Memorandum" - Massachusetts

Form 161 is a Massachusetts Department of Industrial Accidents form also known as the "Employee's Hearing Memorandum". The latest edition of the form was released in August 1, 2013 and is available for digital filing.

Download a PDF version of the Form 161 down below or find it on Massachusetts Department of Industrial Accidents Forms website.

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Download Form 161 "Employee's Hearing Memorandum" - Massachusetts

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The Commonwealth of Massachusetts
FORM 161
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’S
HEARING MEMORANDUM
TO BE COMPLETED BY COUNSEL FOR THE EMPLOYEE PRIOR TO HEARING
DATE:
_____________________________________
EMPLOYEE:
_____________________________________
COUNSEL FOR
EMPLOYEE:
_____________________________________
ADDRESS:
_____________________________________
_____________________________________
DATE OF INJURY:
_____________________________________
CLAIMS:
1. Section 34 from ___________________ to _______________________
2. Section 35 from ___________________ to _______________________
3. Section 36 in the amount of $_______________________
4. Section 13 and 30 in the amount of $____________________________
5. Section 31 from ___________________ to _______________________
or in the amount of $_________________________________________
6. Section 28 from __________________ to ________________________
or in the amount of $_________________________________________
7. Other: ____________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Request Permission to Depose:
Dr. ________________________________________________________
________________________________________________________
(over)
Form 161 - Revised 8/2013 - Reproduce as needed.
The Commonwealth of Massachusetts
FORM 161
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’S
HEARING MEMORANDUM
TO BE COMPLETED BY COUNSEL FOR THE EMPLOYEE PRIOR TO HEARING
DATE:
_____________________________________
EMPLOYEE:
_____________________________________
COUNSEL FOR
EMPLOYEE:
_____________________________________
ADDRESS:
_____________________________________
_____________________________________
DATE OF INJURY:
_____________________________________
CLAIMS:
1. Section 34 from ___________________ to _______________________
2. Section 35 from ___________________ to _______________________
3. Section 36 in the amount of $_______________________
4. Section 13 and 30 in the amount of $____________________________
5. Section 31 from ___________________ to _______________________
or in the amount of $_________________________________________
6. Section 28 from __________________ to ________________________
or in the amount of $_________________________________________
7. Other: ____________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Request Permission to Depose:
Dr. ________________________________________________________
________________________________________________________
(over)
Form 161 - Revised 8/2013 - Reproduce as needed.
Page 2 of 2
ISSUES TO BE ADDRESSED AT HEARING:
a. Stipulations of Fact: _________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
b. Witnesses at Hearing:
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________
4. _________________________________________________
5. _________________________________________________
c. Exhibits to be Marked at Hearing:
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________
4. _________________________________________________
5. _________________________________________________
d. Medical Reports [Under 452 CMR 1.11 (6)]:
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________
4. _________________________________________________
5. _________________________________________________
Medical Reports must be accompanied by the physician’s curriculum vitae or stipulation of
qualifications.
Will an Interpreter be Needed?:
Language to be Interpreted (if applicable):
YES
NO
NOTE: The party offering testimony by a witness who requires an interpreter must provide a certified
interpreter at the time of hearing.
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