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BEFORE THE UNITED STATES DEPARTMENT OF LABOR OFFICE (Department of Labor)

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BEFORE THE UNITED STATES DEPARTMENT OF LABOR
OFFICE OF ADMINISTRATIVE LAW JUDGES
Case Caption and No.
PREHEARING STATEMENT of:
compensation; penalties (under medical benefits;
Claimant
Respondent Director, OWCP
1. Briefly summarize, below or on attached sheet, the facts or circumstances you contend gave rise to this claim, and describe
the nature of the claimed injury or disease.
2. State your contentions as to the place of injury
;
its date
the date disability commenced
;
the date Claimant became
.
3. This claim is for:
);
other
.
4. Your position is that:
(a) The LHWCA applies to this claim?
No Yes
Yes No
Yes No
untimely filed? timely noticed; timely filed; untimely noticed;
No Yes
No Yes
No Yes
No Yes
Yes No
Yes No
(b) At the time of the alleged injury, an employer-employee
relationship existed between Claimant and Employer?
(c) Claimant has suffered injury or disease?
(d) The alleged injury or disease arose out of and in the
course of Claimant's employment?
(e) The claim was
(f) Claimant is/was entitled to: compensation?
medical benefits?
(g) Employer/Carrier is currently providing:
medical benefits?
compensation?
(h) Claimant has reached maximum medical improvement? on
.
In accordance with 29 C.F.R. § 18.80, each party must complete and deliver to the other parties and the presiding judge a signed
prehearing statement no later than the date specified in the Notice of Hearing and Prehearing Order. For cases arising under the
Longshore and Harbor Workers' Compensation Act and its extensions, including the Defense Base Act, a party using this form
will be deemed to have satisfied the requirements of Section 18.80.
and the date employer had notice of injury
aware disability was work related
;
;
§
12. Set forth below or on separate page(s) other contentions, issues or ultimate facts which you will
present at trial (e.g. last responsible employer; § 33(g); collateral estoppel; credits; etc.), and
succinctly brief any novel legal questions.
(i) Claimant has outstanding medical bills?
No Yes
Yes No
no work. alternative work; his/her regular pre-injury work without loss of earnings;
unscheduled; OR
a scheduled injury which caused a
zero;
his/her current earnings;
labor market survey(s);
other facts.
Yes No
conceding entitlement;
denying entitlement on grounds of:
asserting absolute bar;
disability not manifest to employer;
contribution requirement not met?
no pre-existing disability;
Yes No
to: $
$
$
5. Are nature and extent of disability disputed?
6. Is Claimant now working?
in his/her usual employment started on ;
in alternative employment started on .
7. Your position is that Claimant was able to do:
8. Your position is that the alleged injury or disease is:
% loss/loss of use of .
9. Your position is that the alleged injury or disease caused disability which was/is:
temporary total from to
permanent partial from to
temporary partial from to
10. Your position is that Claimant's average weekly wage when injured was $
under § 10 subsection ,
and that his/her retained weekly earning capacity is:
OR $ based on:
11. Is Special Fund relief sought?
If Yes, is the Director:
permanent total from to
13. State below or on separate page(s) the stipulated facts that require no proof (a sample
stipulation form can be found at www.oalj.dol.gov/FORMS.HTM).
18. Estimated time required for you to present your case-in-chief: day(s) or hours
DATE:
/s/:
Representative for
Rev 10/15
14. To the extent not previously provided on this Prehearing Statement form, state below or on
separate page(s) the facts disputed by the parties.
15. Set forth below or on separate page(s) a list of witnesses you expect to call.
16. Set forth below or on separate page(s) a list of the joint exhibits.
17. Set forth below or on separate page(s) a list of the party's exhibits.
19. State below or on separate page(s) any additional information that may aid the parties' preparation for the hearing or the
disposition of the proceeding, such as the need for specialized equipment at the hearing.
Address:
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Number
Fax Number
E-mail Address
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BEFORE THE UNITED STATES DEPARTMENT OF LABOR OFFICE (Department of Labor)

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Completed 26 January 2021

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