Employee Information

Employee Name:

Identity Number:

Diagnosis:

Date of injury:

Date of report:

Company Information

Name of company:

Contact person:

Address:

Telephone number:

Email address:

Occupational Health Doctor and/or Nurse and contact number:

Employer Representative:

Designation:

Work status

Current Work Status:

Signed off on IOD leave

Working in accommodated duties

Able to complete their own job however a number difficulties noted

Completing own occupation

Working accommodated hours

Signed off on other leave

Fit for work, but not yet returned

Working in a temporary alternate occupation

Working in permanent alternate occupation

Date returned to work - if currently working

Current job information

Job title:

The position is defined as:

Sedentary

Light

Medium

Heavy

Very heavy

Position is

Permanent

Contract

Normal work hours:

Overtime hours:

Normal safety equipment utilized:

Job Analysis

Job description:

(A brief overview of the requirements of the job)

Job

tasks

As described by the employee

Reported difficulties - if currently working:

1

2

3

4

5

6

Employer Comments:

Inherent physical demands of the job

Return to work plan

Given the employee's current physical abilities, it is considered that they are currently:

Able to complete their own job

Complete the job, however with difficulty or lower efficiency/productivity

Able to work, but require accommodated duties.

Able to work, but require accommodated hours.

Is not currently able to complete the job

Anticipated return to work date:

Agreed accommodations

Duties agreed:

Work days:

Work hours:

Breaks required:

Tasks to avoid:

The employee did/did not trial the above agreed accommodations during the work visit.

Additional comments:

NAME

TITLE

DATE

CONTACT NUMBER

SIGNATURE

CLIENT

THERAPIST

Physical Demands (where O = Occasionally (<1/3); F= Frequently (1/3 - 2/3); C = Constantly (<1/3))

(denotes if the item was assessed during the work visit)

General observations

(Time/Reps/Loads/Distance

Frequency

throughout the day

Job Tasks

(state number as listed above)

O

F

C

Baseline requirements

Standing

Sitting

Walking

(even/uneven terrain)

Standing

(Static/Dynamic)

Endurance

Climbing Stairs

Step ladders

Scaffold

Platform

Squatting

Crouching

Kneeling

Crawling

Trunk Rotation

Overhead reaching

Forward reaching

Static load

Heavy/repetitive lifting

Ground to waist

Waist to shoulder

Shoulder to above shoulder

Heavy/repetitive carrying

Repetitive pushing/pulling