Job Analysis and Physician Evaluation of Work Capacity

This job analysis is designed to assist in proper job placement.  It can also be used by the examining physician when evaluating an employee’s ability to return to work after an occupational or non-occupational injury or illness.	
		
Instructions:  This form is intended to describe the employee’s job duties and should be completed jointly with input from the employer and employee.  The completed form will be reviewed by the treating doctor to assist with placing or returning the employee to his/her job.  This is an important document and should accurately show the physical and environmental requirements of the employee’s job.  The employer completes Sections I through VI, and then the physician completes the shaded right column of this form after an evaluation of the worker.  For help in completing this form, contact your Companion claims adjuster, nurse case manager, or loss control consultant at 1-800-845-2724.

Employer	Job Title	Department	
	     	     	
Employee	Address	City, State, Zip	
     	     	     	
Claim #	Hours Worked Per Day	Hours Worked Per Week	
     	     	     	
I.  Brief description of job responsibilities.       	Physician Evaluation of Work Capacity
To be filled out by Physician for job placement or for return to work.
	
II. Activity

A.  Sitting………………………………..

B.  Walking……………………………..

C.  Standing……………………………..

D.  Bending (neck)………………………

      Bending (waist)……………………..

E.  Squatting…………………………….

F.  Climbing…………………………….

G.  Reaching (above shoulder)………….

      Reaching (below shoulder)………….

H.  Kneeling……………………………..

I.  Crawling……………………………...

J.  Twisting (neck)………………………

     Twisting (waist)……………………...	Number of Hours
   0         1          2         3          4          5         6          7         8+

                                                          

                                                          

 

                                                          

                                                          

                                                          

                                                          	
 Yes         No     Comments
                      

                      

                      

                      

                      

                      

                      

                      

                      

                      

                      

                      

                      
	
III.  Weight
     Please indicate the daily Lifting and Carrying requirements of the job.  Indicate the height the object is
      lifted from the floor, table or overhead location and the distance the object is carried.		
	Lifted
Yes No  Distance
	Carried
Yes No  Distance	
             Number of Hours
              1    2    3    4   5   6    7   8+	

Yes         No     Comments	

A.  0 to 10 pounds	
          	
          	Lifted           Carried         	 
                     	

B.  11 to 25 pounds	
          	
          	Lifted           Carried         	 
                     	

C.  26 to 50 pounds	
          	
          	Lifted           Carried         	 
                     	

D.  51 to 75 pounds	
          	
          	Lifted           Carried         	 
                     	

E.  76 to 100 pounds	
          	
          	Lifted           Carried         	 
                     	

F.  100 + pounds  	
          	
          	Lifted           Carried         	 
                     	

Describe the heaviest item required to carry and the distance to be carried.       		
Companion Property & Casualty Group. 01-2005.

Job Analysis (Continued)	Work Capacity (Continued)	
IV.  Hand and Arm Use	Right
Yes        No	Left
Yes       No	  Number of hours
  1    2     3     4    5     6    7     8+	Right             Left
Yes   No       Yes   No    Comments	
A.  Hand Use:  Dominant Hand…….	         	         		                          
	
B.  Is repetitive use of hand required?	         	         	               	                          
	
C.  Simple Grasping………………...	         	         	               	                          
	
D.  Power Grasping…………………	         	         	               	                          
	
E.  Fine Manipulation………………	         	         	               	                          
	
F.  Pushing Pulling………………….	         	         	               	                          
	
G. Office Work Activities…………..
	         	         	               	                          	
VI.  Please indicate if your job requires:	  Yes         No	Yes         No     Comments
	
A.  Driving cars, trucks, forklifts and other equipment?………………………………….	             	                     
	
B.  Working around equipment and machinery?…………………………………………	             	                     
	
C.  Walking on uneven ground?………………………………………………………..	             	                     
	
D.  Exposure to excessive noise?…………………………………………………………	             	                     
	
E.  Exposure to extremes in temperature, humidity or wetness?…………………………	             	                     
	
F.  Exposure to dust, gas, fumes or chemicals?…………………………………………..	             	                     
	
G.  Working at heights?…………………………………………………………………..	             	                     
	
H.  Operation of foot controls or repetitive foot movement?…………………………….	             	                     
	
I.  Use of special visual or auditory protective equipment?………………………………	             	                     
	
J.  Working with bio-hazards such as:  blood-borne pathogens, sewage, hospital waste,
     etc……………………………………………………………………………………..	             	                     	
If yes, describe       

	
Employee Comments:       

Employer Comments:       

Temporary transitional work options are available at this company?             Yes        No
	
Employer Contact Name	ER Contact Title	Printed Name of Treating Physician	
     	     		
Employer Representative Signature	Date	Signature of Treating Physician	
	     	     	
Employee’s Signature	Date	Physician’s Telephone	
	     	     	
Qualified Rehab Rep Signature (if applicable)	Date	Date	
	     		

Companion Property & Casualty Group. 01-2005.