COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar ANALYSIS N.H. WORKERS’ COMPENSATION TASK No. In compliance with RSA 281-A:23-b, the employer with 5 or more : employees must provide temporary alternative/ JUDICIAL SUBPOENA Plaintiff(s) transitional work opportunities to all employees temporarily disabled by a work-related injury or illness. Task is defined as one of the -againstdistinct activities that constitute logical and necessary steps in the performance of a : job. A task analysis, for the purpose of this section, is the evaluation of the physical requirements of each task of a particular job or work assignment. : Employer ______________________________________ Employee _____________________________________ Telephone # ___________________________________ W.C. Insurer ___________________________________ : Defendant(s) : . . . . . . . . . _________________________________________________________________________________ Employer .Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Complete the following information to describe the employee’s job at the time of injury: Job Title ___________________ Usual Job? Yes ___ THE PEOPLE OF THE STATE OF NEW YORK No ____ General Description/Purpose ______________ ________________________________________________________________________________________________ TO Department ____________________________________ Supervisor _____________________________________ Description of Tasks (use additional page as needed): GREETINGS: 1. _______________________________________________________________________________________________ 2. _______________________________________________________________________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before the Honorable at the Court 3. _______________________________________________________________________________________________ , County of located at 4. _______________________________________________________________________________________________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 5. _______________________________________________________________________________________________ Tools & Equipment _________________________________________________________________________________ Your failure __________________________________________________________________________ Describe Special Demands to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a ________________________________________________________________________________________________ result of your failure to comply. PHYSICAL DEMANDS Witness, Honorable , one of the Justices of the Complete the following to show the maximum physical demand for all of the tasks listed above. For example, if Tasks Court require no bending but Task dayrequires “occasional” bending, the overall job must be rated as requiring County, , 20 1 through 4 in #5 of occasional bending. JOB REQUIRES: part of day bending kneeling squatting climbing standing walking sitting reaching driving fine motor skills Continuous Frequent Occasional 100%-67% 66%-34% 33%-1% JOB REQUIRES: (Attorney must sign above and type name below) maximum lifting/carrying of ______ lbs. frequent lifting/carry of _________ lbs. WORK SCHEDULE: Attorney(s) for Number of hours/day _______________ Number of days/week ______________ DoesOffice and P.O. Address job require Repetitive Motions? (check if applicable) wrist elbow shoulder ankle Right Left Telephone No.: Facsimile No.: ATTACH JOB DESCRIPTION IF AVAILABLE E-Mail Address: ____________________________________ ____________________________________ Mobile Tel. No.: Completed by Title __________________ Date American LegalNet, Inc. www.USCourtForms.com