1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com JOB DESCRIPTION CLAIMS DIVISION SFN 54392 (10/2010) Claim Number Injured Worker’s Name Job Title Transitional Pre-Injury Employer Risk Management Contact Is transitional work currently being performed? If yes, Yes No Modified Alternate What impact will the injury have on the injured worker’s ability to get to work or to do regular duties in the usual way? Can arrangements be made so injured worker can be doing something productive at work during recovery period? Loss control referral? Yes No Is there a job description outlining essential job functions? Yes No If yes, forward to WSI (adjuster create diary). If no, complete the following: PHYSICAL REQUIREMENTS ASSESSMENT Not Performed (NP) Rare (R) = 1-5% Occasionally (O) = 6-33% Note: Frequencies are based on an 8 hour workday. 1. Employee may be required to sit: 2. Employee may be required to stand: 3. Employee may be required to walk: 4. Employee may be required to lift/carry: a. 0-10lbs b. 11-20lbs c. 21-50 lbs d. 51-100 lbs Frequently (F) = 34-66% Constantly (C) = 67-100% NP NP NP NP R R R R O O O O F F F F C C C C 5. Employee must be able to lift overhead: a. 0-10lbs b. 11-20lbs c. 21-50 lbs d. 51-100 lbs NP NP NP NP R R R R O O O O F F F F C C C C 6. Employee must be able to Bend Crawl Kneel Squat Reach Above Head Work at Heights Drive a Vehicle Twist NP NP NP NP NP NP NP NP R R R R R R R R O O O O O O O O F F F F F F F F C C C C C C C C 7. Repetitive Motion Light Grasping Forceful Grasping Pushing/Pulling Fine Dexterity NP NP NP NP R R R R O O O O F F F F C C C C 8. Environmental Considerations: (hot/cold temperatures, vibration, chemical exposure, noise exposure) 9. Equipment: (tools, machinery, equipment) Additional comments: Signature Title Date American LegalNet, Inc. www.FormsWorkFlow.com