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Task Analysis Form. This is a New Hampshire form and can be use in General Workers Comp.
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Tags: Task Analysis, New Hampshire Workers Comp, General
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
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