BEFORE THE UNITED STATES DEPARTMENT OF LABOR 

 OFFICE OF ADMINISTRATIVE LAW JUDGES

Case Caption and No.

PREHEARING STATEMENT of:

 compensation; medical benefits; penalties (under

 Claimant

 Director, OWCP Respondent

1. Briefly summarize, below or on attached sheet, the facts or circumstances you contend gave rise to this claim, and describe 

 the nature of the claimed injury or disease.

2. State your contentions as to the place of injury ;

 its date the date disability commenced ; the date Claimant became

.

3. This claim is for: );

other .

4. Your position is that:

(a) The LHWCA applies to this claim?

 Yes No

 Yes No

 Yes No

 timely noticed; untimely filed? timely filed; untimely noticed;

 Yes No

 Yes No

 Yes No

 Yes No

 No Yes

 Yes No

(b) At the time of the alleged injury, an employer-employee 

 relationship existed between Claimant and Employer?

(c) Claimant has suffered injury or disease?

(d) The alleged injury or disease arose out of and in the 

 course of Claimant's employment?

(e) The claim was

(f) Claimant is/was entitled to: compensation?

medical benefits?

(g) Employer/Carrier is currently providing:

medical benefits?

compensation?

(h) Claimant has reached maximum medical improvement? on .

In accordance with 29 C.F.R. § 18.80, each party must complete and deliver to the other parties and the presiding judge a signed 

prehearing statement no later than the date specified in the Notice of Hearing and Prehearing Order. For cases arising under the 

Longshore and Harbor Workers' Compensation Act and its extensions, including the Defense Base Act, a party using this form 

will be deemed to have satisfied the requirements of Section 18.80. 

aware disability was work related and the date employer had notice of injury ;

;

§
12. Set forth below or on separate page(s) other contentions, issues or ultimate facts which you will 

 present at trial (e.g. last responsible employer; § 33(g); collateral estoppel; credits; etc.), and 

 succinctly brief any novel legal questions.

(i) Claimant has outstanding medical bills?

 Yes No

 No Yes

 no work. alternative work; his/her regular pre-injury work without loss of earnings;

 unscheduled; OR

 a scheduled injury which caused a 

 zero;

 his/her current earnings;

 labor market survey(s);

 other facts.

 No Yes

 conceding entitlement;

 denying entitlement on grounds of:

 asserting absolute bar;

 disability not manifest to employer;

 contribution requirement not met?

 no pre-existing disability;

 No Yes

to: $

$

$

5. Are nature and extent of disability disputed?

6. Is Claimant now working?

in his/her usual employment started on ;

in alternative employment started on .

7. Your position is that Claimant was able to do:

8. Your position is that the alleged injury or disease is:

% loss/loss of use of .

9. Your position is that the alleged injury or disease caused disability which was/is:

temporary total from to

permanent partial from to

temporary partial from to

10. Your position is that Claimant's average weekly wage when injured was $

under § 10 subsection , and that his/her retained weekly earning capacity is:

OR $ based on:

11. Is Special Fund relief sought?

If Yes, is the Director:

permanent total from to

13. State below or on separate page(s) the stipulated facts that require no proof (a sample 

 stipulation form can be found at www.oalj.dol.gov/FORMS.HTM).
18. Estimated time required for you to present your case-in-chief: day(s) or hours

DATE: /s/:

Representative for 

Rev 10/15

14. To the extent not previously provided on this Prehearing Statement form, state below or on 

 separate page(s) the facts disputed by the parties.

15. Set forth below or on separate page(s) a list of witnesses you expect to call. 

16. Set forth below or on separate page(s) a list of the joint exhibits.

17. Set forth below or on separate page(s) a list of the party's exhibits.

19. State below or on separate page(s) any additional information that may aid the parties' preparation for the hearing or the 

disposition of the proceeding, such as the need for specialized equipment at the hearing.

Address:

Telephone 

Number

Fax Number

 E-mail Address