Reported on behalf of: N e w Y o r k S t a t e I n s u r a n c e F u n d
Carpal Tunnel/Repetitive Trauma Claims
Date of this report:
Claimant:
NYSIF Case#:
-Unit -
D/A:
Agency Name: NWI Investigative Group, Inc.
Investigation Date:
Person who conducted investigation:
Title: Investigator
Agency Investigation No.:
Phone
Field
By Appointment
NYSIF Investigation No.:
Preliminary report #:
Final report
Person interviewed:
Of (name of business):
Address visited:
Telephone number:
1. Describe claimant's current job duties.
(Include a complete and thorough description of job duties, tasks performed to include position
and motion of hands, wrists and arms. Daily frequency and duration of each task).
2. Was the claimant provided with a wrist rest when using equipment such as computer
keyboards?
3. Was the claimant allowed to take breaks?
4. How often and duration?
5. How long has the claimant performed each task while an employee of this assured?
6. Did the claimant perform the same or similar tasks for previous employers?
7. Does the claimant have a systemic disease such as diabetes, high blood pressure, thyroid disease, heart
condition, lupus or arthritis?
If yes, list which one, when, where and with whom treated)
8. Other systemic disease?
If yes, explain (list when, where and with whom treated)
9. Pregnant?
If yes, explain (list when, where and with whom treated)
10. Is claimant engaged in any activities outside of work such as bowling, knitting, golf, crocheting, arts
and crafts, skiing or skating?
If yes, indicate which one and amount of time spent per week)
11. Other repetitive hand activity?
If yes, explain (indicate amount of time spent per week)
12. Was claimant ever treated for carpal tunnel syndrome, tendonitis, over use syndrome?
If yes, explain
13. When did the claimant first notice symptoms (tingling, numbness, etc.)?
14. Does the claimant have other employment?
If yes, explain (please include job title and job description)
15. List prior medical problems, complaints, and surgeries:
Report text:
Approved by: William J. Donnelly
Rev 12/07
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