RESET
Department of Labor and Industries Vocational Services
EMPLOYER'S JOB DESCRIPTION
Claim # Claimant Date Title
Job Title Employer Phone # Description completed by: Essential task description:
Machinery, tools, equipment and personal protective equipment. (Please submit MSDS if appropriate.)
PHYSICAL DEMANDS
N: Never (not at all) S: Seldom (1-10% of the time) O: Occasional ( 11-33% of the time) Frequency Sitting Standing Walking Driving Lifting ( )lb. Carrying: ( )lb. Pushing/Pulling: ( ) lb. Climbing Stairs/Ladders Bending/twisting at waist Kneeling/squatting Crouching/Kneeling Crawling Reaching above shoulder Repetitive Motion Handling/Grasping Fine Finger Manipulation Talking Hearing Seeing Other F: Frequent (34%-66% of the time) C: Constant (67%-100% of the time)
Description of Task
FOR PHYSICIAN USE ONLY
Physician Approval No Yes Full-time Part-Time Hours per week If part-time, worker is expected to progress to full-time work by (date)
Date
Physician Signature
Physician Name
F252-040-000 employer's job description 06-2006