Free F252-040-000 employers job description - Washington


File Size: 94.7 kB
Pages: 1
File Format: PDF
State: Washington
Category: Workers Compensation
Author: Forms Management
Word Count: 150 Words, 1,058 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.lni.wa.gov/Forms/pdf/252040af.pdf

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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