COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. Analysis of upper extremity use :for Calendar No. office activities Plaintiff(s) Worker name: -againstJob title Equipment/modifications provided/potential modifications: : Claim #: JUDICIAL SUBPOENA : Employer: : Work hours/Days per week: : Form completed by (include title): Defendant(s) : ...................................................... Minutes Times Job tasks at a time per day Describe – see instructions on reverse. Hours per day Restrictions (For completion by physician) If yes, provide detail below. Keyboarding: THE PEOPLE OF THE STATE OF NEW YORK Mousing: TO Handwriting: Yes No Yes No Yes No Gripping: Yes No GREETINGS: Reaching/handling: Yes No WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 10-Key/Calculator: Yes No , the Honorable at the Court located at County of Lifting/carrying: Yes No in room , on the day of , 20 , at o'clock in the noon, and at any recessed Filing: adjourned date, to testify and give evidence as a witness in this action on the part of the or Yes No Phone/headset: Yes No Pushing/pulling: failure to comply with this subpoena is punishable as a contempt of court Yes will make you liable to Your and No the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Sorting: Yes No result of your failure to comply. Stapling/punching: Yes No Witness, Honorable , one of the Justices of the Other (describe): Yes No Court in County, day of , 20 Physician: Please complete remainder of form. Restrictions: (Attorney must sign above and type name below) Attorney(s) for Worker is released for modified work effective: Worker is released for regular work effective: Physician’s signature: X 440-3289 (3/01/DCBS/WCD/WEB) Office and P.O. Address (date) (date) Telephone No.: Facsimile No.: Date: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. Tips for form completion No. : Calendar 1. In the form heading under “Equipment/modification provided/potential modifications,” describe any : JUDICIAL SUBPOENA ergonomic equipment already in place and ifPlaintiff(s) the worker’s hours can be modified and tasks reassigned. -against- : 2. Under “Job tasks,” provide as much relevant information as possible to ensure the physician receives enough information to determine what the worker is capable of :doing. Please consider the following: Keyboarding: Because keyboarding demands differ according to task, include how much time the worker : spends on each of the following: e-mail, word processing, data entry, and “other” keyboarding. Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . depending . . . . Mousing: .Physical .movement. differs. substantially, . . . . . . . . . . upon the type of mouse used. Enter the type of device: standard mouse, track ball, mouse pad, etc. Handwriting: Describe handwriting duties in detail. Meeting minutes are more demanding than an occasional THE PEOPLE OF THE STATE forms requires signature. Completion of carbonless OF NEW YORKgreater force than plain-paper forms. Gripping: Say if gripping is narrow or wide, and if it is forceful, sustained, and/or repetitive. TO Reaching/Handling: Describe reaching requirements, including: length of reach, if the hands carry weight during the reach, if the reach is up to shelving or down into file drawers, etc. GREETINGS: 10-Key/Calculator: Say whether the worker uses the computer keyboard for calculations or a different machine/calculator; the force required and reach involved differ substantially. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before the Honorable at the Court Lifting/Carrying: Enter the weight of the items, the distance of the lift, how the items are carried, and how far located at County of they are carried. in room , on the day of , 20 , at o'clock in the noon, and at any recessed Filing: Enter the weight of the items being filed, as a height of the drawers where the filing is done, whether or adjourned date, to testify and give evidence the witness in this action on the part of the drawers need to be pulled out, and how much weight is in them. Phone/Headset: Enter the number of phone calls, in and out, on an average day. Say if a headset is always used and, if not, describe failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Your the reach required. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Pushing/Pulling: Explain what the worker is pulling and/or pushing and whether it is loaded with items or result of your failure to comply. empty, the amount of force required to push or pull, and how much weight is involved. Witness, Honorable one of the Justices of the Sorting: Describe the type of sorting, the items being sorted, and if reaching ,is involved. Court in County, day of , 20 Stapling/Hole Punching: Describe the tools involved and whether they are manual or electric. Other: Describe any other tasks done by the worker that involve upper extremity use. Include other helpful information, e.g., “the worker telecommutes two days a week.” The home officeabove and type to bebelow) (Attorney must sign may need name addressed, as well. Restrictions: After the employer completes the job task descriptions, the physician will complete the Attorney(s) for “Restrictions” column and check “yes” next to any job task for which restrictions are necessary, given the worker’s injury and recovery status. In the space provided, the physician should then enter specific restrictions for the job task(s) and complete the remainder of the form. Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 2 American LegalNet, Inc. www.USCourtForms.com ,