Unclassified Staff Advisory Council

The Office of Risk Management recently required all state agencies to have every employee complete the E-2 Questionnaire Form as required by law. The information is needed in the event that a work-related injury or disability is caused or made worse by a pre-existing condition, the employer may be able to seek reimbursement of the benefits paid from the Louisiana Second Injury Fund.

To accomplish this task, Human Resources has decided to distribute the questionnaire in a two phase implementation starting with employees whose last name begins with A-L. These employees should have already received the questionnaire. The remaining employees whose last name begins with M-Z will receive the questionnaire in coming months.

Since the questionnaire was distributed to the first group of employees, a number of concerns/questions have been brought to our attention. These concerns are understandable because the form contains questions dealing with confidential medical information. Below are clarifications to concerns of individual employees and also the Unclassified Staff Advisory Council:

• The form is completed by the employee only.
• Once completed the employee may have their supervisor or any other university employee witness their signature. The witness is not to read or attempt to verify any information on the form. They are ONLY witnessing your signature.
• Once signed and witnessed, YOU are to place the form in the envelope provided and seal it.
• You are to complete the information requested on the front of the envelope. You may use your campus wide ID# (also know as your employee ID#) in place of the SS#.
• When we receive the E-2 questionnaire form it remains sealed, and is put into the employeeís confidential ADA medical file. Upon separation of the employee, the ADA and the employeeís personnel files are both moved to our inactive file cabinet (locked). It is not forwarded to any state office and will eventually (after several years) be purged from our inactive file cabinet, boxed and stored with all other terminated files on campus.

Should you have any other questions or concerns, please feel free to contact Donna Adams (ext. 4041) or Ken Cortez (ext.4039).

Thank you.

Ronald P. Boudreaux
Director