STATE OF CALIFORNIA
Division of Workers' Compensation
Disability Evaluation Unit
EMPLOYEE'S DISABILITY QUESTIONNAIRE
DEU Use Only
This form will aid the doctor in determining your permanent impairment or disability. Please complete this form and
give it to the physician who will be performing the evaluation. The doctor 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.
Employee
First Name
MI
Last Name
SSN (Numbers Only)
Street Address 1/PO Box (Please leave blank spaces between numbers, names or words)
Street Address 2/PO Box (Please leave blank spaces between numbers, names or words)
International Address (Please leave blank spaces between numbers, names or words)
MM/DD/YYYY
MM/DD/YYYY
City
Date of Birth
Date of Injury
Employer
Nature of Employers Business
Claim Number 1
State
Zip Code
DWC-AD form100 (DEU) Page 1 (REV. 11/2008)
DWC-AD form100 (DEU)
