WC-240a JOB ANALYSIS GEORGIA STATE BOARD OF WORKERS' COMPENSATION JOB ANALYSIS Instructions: File this form as an attachment to a WC-240 Board Claim No. Employ ee Last Name Employ ee First Name Name M.I. SSN or Board Tracking # Date of Injury Contact Person EMPLOYER Job Title Position Telephone Number Prepared by: Date: SCHEDULE Shift(s): WORK PACE Days: Self-Paced? Yes Hours / Week: Overtime: Rate of Pay: Incentive Based? No Yes Machine Paced? No Yes No Production Standards (Define Requirements): JOB DESCRIPTION (What is the purpose and objective of this job?): WEIGHT LIFTING Never Occasional (up to 1/3 of the time) Frequent (1/3 to 2/3 of the time) Constant (over 2/3 of the time) OBJECTS Low est Point Lift/Low er Highest Point Lift/Low er Height FREQUENCY Height Negligible 10 lbs. Max. 20 lbs. Max. 25 lbs. Max. 50 lbs. Max. 100 lbs. Max. Over 100 lbs. CARRYING Max. Distance Carried Negligible 10 lbs. Max. 20 lbs. Max. 25 lbs. Max. 50 lbs. Max. 100 lbs. Max. Over 100 lbs. PUSH/PULL MAX FORCE Max. Distance Moved Negligible 10 lbs. Max. 20 lbs. Max. 25 lbs. Max. 50 lbs. Max. 100 lbs. Max. Over 100 lbs. -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. WC-240a REVISION . 07/2011 240a 1 OF 2 34-9-18 AND 34-9-19). JOB ANALYSIS American LegalNet, Inc. www.FormsWorkFlow.com WC-240a JOB ANALYSIS GEORGIA STATE BOARD OF WORKERS' COMPENSATION POSTURES / MOVEMENTS MAX. CONSEC. MIN/HOURS TOTAL DAILY HOURS POSITION CHANGE OPTIONAL? Occasional (up to 1/3 of the time) Frequent (1/3 to 2/3 of the time) FURTHER DESCRIPTION Constant (over 2/3 of the time) Sitting Standing (in place) W alking Use Arm/Leg Controls Never Bending Turn/Twisting Kneeling Squatting Crawling Climbing Reaching (out) Reaching (up) W rist Turning Grasping Pinching Finger Manipulation LIST EQUIPMENT, MACHINES, TOOLS, VEHICLES USED SPECIAL CONSIDERATIONS (ENVIRONMENTAL CONDITIONS, VISION, HEARING, HEIGHT) Employer's Signature (Title) Date TO BE FILLED OUT BY THE AUTHORIZED TREATING PHYSICIAN 1. Employee can perform this job w hile taking medications as prescribed Yes No 2. I do release the employee to the job described 3. I do not release the employee to the job described 4. I only release the employee to the job described w ith the follow ing restrictions/limitations/modifications: Physician's Name Physician's Signature Date -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. WC-240a REVISION . 07/2011 240a 2 OF 2 34-9-18 AND 34-9-19). JOB ANALYSIS American LegalNet, Inc. www.FormsWorkFlow.com