State of Wisconsin Department of Administration Chs. 102 and 230.36, Wis. Stats. DOA-6125 (R12/2001) COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) : Instructions: Index No. Physician: Complete section II including reverse side, and return completed form to Calendar the employing agency listed. No. JUDICIAL SUBPOENA This form can be made available in accessible formats upon request to qualified individuals with disabilities. -against- Physician's Certification : : : I. General Information - To be completed by employing agency Employee Name (As appears on Payroll) Employing Agency - Include Street Address or P.O. Box, City, ZIP + 4 Date of Accident (mm/dd/ccyy) Agency Contact Person Date of Birth (mm/dd/ccyy) Claim Number Defendant(s) : ...................................................... Brief Work Description Phone Number ( ) Description of Injury: The employee claims the injury or disease occurred as follows: THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: II. Physician's Statement - To be completed by physician. Required for worker's compensation payments. The above named employee is applying for benefits through either Worker's Compensation (Ch. 102, Wis. Stats.) or "Hazardous Employment" (Sec. 230.36,7, Wis. Stats.) withthat State of Wisconsin. WE COMMAND YOU, the all business and excuses being laid aside, you and each of you attend before Physician's Name (Type or Print) Date of Initial Treatment Date of Last Treatment/Exam , the Honorable at the Court located at County of Is employee currently under Has employee been discharged Address in room , on the day of , 20 your ,care for job relatedin the from treatmentat any recessed at o'clock injury noon, and for this injury? or disease? action on the part of the or adjourned date, to testify and give evidence as a witness in this Yes No Yes No Diagnosis: I hereby certify that the above named employee is under my care for: (Describe physical problems resulting from injury or disease.) Your failure 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. surrounding the job-related injury or disease described by the employee? Yes ­ Indicate the reasoning that led to this conclusion: Witness, Honorable , one of the Justices of the Court in County, day of , 20 Is it your opinion to a reasonable degree of medical certainty that the above named individual's condition resulted from the circumstances No (Attorney must sign above and type name below) Did this employee have a pre-existing condition prior to the work Did the work injury aggravate the pre-existing condition beyond injury? normal progression? Yes No Yes No Do you expect that any further treatment will be necessary to cure or relieve the employee from the effects of this injury? Attorney(s) for Yes ­ How much longer and what type of treatment? (include prescribed medications) No Date employee will be able to resume work: Actual Estimated Return to work - Check all that apply. Full Time Without Work Restrictions Half Time With Work Restrictions as Checked on Page 2. Other ­ Please Specify: Prognosis: Office and P.O. Address Has employee been advised? Yes No Is permanent disability expected? Yes ­ Complete REVERSE SIDE No Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: -OVER- American LegalNet, Inc. www.USCourtForms.com Work Restrictions: Employees may be assigned to alternate work duties while recovering from their injury. Assigned duties will be based on limitations determined by the doctor. COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. Check Current Work Performance Limitations Sedentary Work. Lifting 10 pounds maximum and 1. In an 8 hour work day patient may: : a. occasionally lifting and/or carrying such articles Plaintiff(s) Stand / Walk as JUDICIAL SUBPOENA dockets, ledgers, and small tools. Although a sedentary None 4-6 Hours -against: job is defined as one which involves sitting, a certain amount of walking or standing is often necessary in 1-4 Hours 6-8 Hours : carrying out job duties. Jobs are sedentary if walking and b. Sit standing are required only occasionally and other sedentary criteria are met. 1-3 Hours: 3-5 Hours 5-8 Hours Light work. Lifting 20 pounds maximum with frequent c. Drive Defendant(s) : . . . . . . . . . . . . . . . . . weighing . . . . lifting . and/or . carrying . of. . objects . . . . . . . . . up . to. .10. . . . . . . . . . . . . . . . 1-3 Hours 3-5 Hours 5-8 Hours pounds. Even though the weight lifted may be only a negligible amount, a job is in this category when it 2. Patient may use hand(s) or repetitive motion requires walking or standing to a significant degree of Single Grasping Pushing & Pulling THE PEOPLE arm and/or leg controls. pushing and pulling of OF THE STATE OF NEW YORK Fine Manipulation Light Medium Work. Lifting 30 pounds maximum with TO frequent lifting and/or carrying of objects weighing up to 3. Patient may use foot / feet for repetitive movement as in operating foot controls: 20 pounds. Medium Work. Lifting 55 pounds maximum with frequent lifting and/or carrying of objects weighing up to 25 GREETINGS: pounds. Yes 4. Patient may: Not at all No Frequently Continuously (34-66%) (67-100%) each of you attend before WE Lifting 75 pounds that all business Light Heavy Work. COMMAND YOU,maximum with frequent lifting and/or carrying of objects weighing up to the Honorable 40 pounds. of located at County in room day of Heavy Work. Lifting 100 , on the maximum with frequent pounds lifting or adjourned date, toobjects and give evidence as and/or carrying of testify weighing up to 50 pounds. and excuses being laid at the Bend Court a. b. Twist Occasionally (1-33%) aside, you and , , 20 , at o'clock in the noon, and at any recessed c. Squat a witness in this action on the part of the d. Climb e. Reach Your Will above limitations be: failure to comply with this subpoena is punishable as a may be harmful: Other activities which 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 Temporary, until (date ­ mm/dd/ccyy)): result of your failure to comply. Other con