Return completed form to: Job Function Evaluation Claim Number Date of Injury Employee Name BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 Company Job Title Check one: Current Job Alternate Job Job Function (provide basic description of the job duties) Work Location: Indoors Outdoors Below Ground Elevated Areas Personal Protective Equipment Required? Yes Heated Not Heated Temp. Extremes No Temp. Extremes Work Postures (Work is performed in which postures? Please indicate frequency.) Standing Yes No Continuous Sitting Yes No Continuous Walking Yes No Continuous Climbing Yes No Continuous Kneeling Yes No Continuous Pushing Yes No Continuous Pulling Yes No Continuous (6 – 8 hours a day) Physical Demand: Lifting Frequent Frequent Frequent Frequent Frequent Frequent Frequent No Infrequent Infrequent Infrequent Infrequent Infrequent Infrequent Infrequent (2 – 6 hours a day) (0 – 2 hours a day) Describe Materials Weight of Materials Describe Materials Weight of Materials How Frequently Carrying Distance Carried Describe List of Tools Used Work Hours Number/Length of Breaks Please Indicate any Other Special or Unusual Job Demand(s) Completed By Physician Release to perform these duties? Yes No Title Date of Release Date Physician Signature Updated: 10/08 American LegalNet, Inc. www.FormsWorkFlow.com