Worker's Compensation Questionnaire - Miami Dade College - mdc 2026

1. Click ‘Get Form’ to open the Worker's Compensation Questionnaire in the editor.
2. Begin by entering your Employee's Name and SSN in the designated fields at the top of the form.
3. Review the list of medical conditions provided. Check all that apply to you, ensuring you accurately reflect your health history.
4. If you checked any conditions, provide a brief explanation in the space provided below that question.
5. Answer whether you have ever been hospitalized and provide details if applicable. Repeat this for psychological or psychiatric treatment.
6. Fill in your family doctor’s name and any medication allergies you may have.
7. Finally, read through the certification statement, sign it electronically, and enter the date before submitting your completed form.

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