State of California Division of Workers' Compensation DESCRIPTION OF EMPLOYEE'S JOB DUTIES DWC - AD 10133.33 INSTRUCTIONS: This form shall be developed jointly by the employer and employee and is intended to describe the employee's job duties. The completed form will be reviewed to determine whether the employee is able to return to work. Employee Last Name Employee First Name MI Claim #: Employer Name Job Address Job Title: Hrs. Worked Per Day Hrs. Worked Per Week Description of Job Responsibilities: (Describe All Job Duties): Please check one: Regular Duty Modified Duty Alternative Work 1. Check the frequency of activity required of the employee to perform the job. ACTIVITY (Hours per day) Sitting Walking Standing Bending (neck) Bending (waist) Squatting Climbing Kneeling Crawling Twisting (neck) Twisting (waist) Hand Use: Dominant hand: Simple Grasping (right hand) Simple Grasping (left hand) Power Grasping (right hand) Power Grasping left hand) Fine Manipulation (right hand) Fine Manipulation (left hand) Pushing & Pulling (right hand) Pushing & Pulling (left hand) Reaching (above shoulder level) Reaching (below shoulder level) Keyboarding with both hands Right Left NEVER 0 HOURS OCCASIONALLY UP TO 3 HOURS FREQUENTLY 3-6 HOURS CONSTANTLY 6-8+ hours Is repetitive use of hand required? DWC AD 10133.33 (SJDB) Eff: 1/1/14 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 2. Please indicate the daily Lifting and Carrying requirements of the job: Indicate the height the object is lifted from floor, table or overhead location and the distance the object is carried. LIFTING Never 0 hrs 0 - 10 lbs . 11 - 25 lbs. 26 - 50 lbs. 51 - 75 lbs. 76 - 100 lbs. 100+ lbs. Occasionally Frequently up to 3 hrs 3-6 hrs Constantly Height 6-8+ Never 0 hrs. CARRYING Occasionally up to 3 hrs. Frequently Constantly 3-6 hrs. 6-8+ hrs. Distance Describe the heaviest item required to carry and the distance to be carried: 3. Please indicate if your job requires: YES NO a. Driving cars, trucks, forklifts and other equipment? b. Working around equipment and machinery? c. Walking on uneven ground? d. Exposure to excessive noise? e. Exposure to extremes in temperature, humidity or wetness? f. Exposure to dust, gas, fumes, or chemicals? g. Working at heights? h. Operation of foot controls or repetitive foot movement? i. Use of special visual or auditory protective equipment? j. Working with bio-hazards such as: blood borne pathogens, sewage, hospital waste, etc.? Employee Comments (IF YES, PLEASE BRIEFLY DESCRIBE) Employer Comments: Employer Contact Name: Employer Contact Title: Employer Representative Signature: Employee's Signature: Date: Date: American LegalNet, Inc. www.FormsWorkFlow.com DWC AD 10133.33 (SJDB) Eff: 1/1/14 Page 2 of 2