Federal Workers’ Compensation Questionnaire Thank you for reaching out to our office regarding your Federal Workers Compensation Plan. This a 2 step questionnaire that will first ask about your contact information and how you found Harris Federal. Then we'll ask about your job, injury, and current case status. If there's a question you're not sure about, it's ok to skip it for now and we'll follow up later. When you complete this questionnaire by pressing the "Send My Info" button on the final screen, your information will go to one of our intake specialists for review. Afterwards, a member of our team will contact you to arrange for a telephone appointment to discuss your answers. First, tell us how to contact you and how you came to contact us:Name* First Last Email* Phone*Preferred Contact MethodPhone callEmailText messageAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about Harris Federal Law Firm?---- Select one from below ----Referred by attorneyGoogle search (or other search engine)Social media (e.g. Facebook, Instagram, etc)Directory listing (e.g. Yelp, Findlaw, etc)OtherWho referred you and where are they located?So, how did you find us? We love a good story! Thanks! Now tell us a bit about your job and case status, if any:What federal government agency do you work for?*What part of your body was injured at work?*When did your injury occur? MM slash DD slash YYYY Have you had surgery?*YesNot yet, but it is scheduledNot yet, but it is NOT scheduledNo and I'm not sure if I need itNo and my doctor has determined I may not need itNo and I need help with thisWhen was your surgery? It's OK if you need to approximate. MM slash DD slash YYYY What day are you having surgery? MM slash DD slash YYYY We're here to help! The process can get confusing and overwhelming sometimes. The Harris Federal team is here to hop in the trenches with you and help you get the outcomes you deserve.Has your OWCP case been accepted?* Yes No I'm not sure Have you started receiving wage loss benefits?*YesNoI'm not sureWhen did you start receiving wage loss benefits? MM slash DD slash YYYY Is there anything else we need to know? Tell us here:NameThis field is for validation purposes and should be left unchanged. Δ
