Form E-2 Medical Questionnaire

What is the E-2 form?

The purpose of the E-2 Form is to request pre-existing medical condition information, in accordance with Louisiana R.S. 23:1208.1. See the link “Notice” on left side of this page for more information.

Who completes the E-2 Form?

All employees, with the exception of Gratis, complete this form at the time of hiring.

Where can you pick-up an E-2 Form?

Your department is responsible for purchasing E-2 Forms from the Print Shop. Form # 7252

What if an employee does not want to complete a E-2 Form?

They can sign the signature sheets sent to the department. The employee should be aware that failure to complete an E-2 Form may result in the forfeiture of Workers’ Compensation and Medical Benefis under the Louisiana Workers’ Compensation statute (LA. R. S. 23:1208.1).

Where can the E-2 Forms be returned?

Human Resource Management Benefits section, Allied Health Bldg., Room 124 OR take it to the HRM drop box located on the ground floor of the hospital, K-Wing hallway, outside the Cafeteria near the Pharmacy.

Where can we return the signature sheets?

Human Resource Management Benefits section, Allied Health Bldg., Room 124