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Description Of Employees Job Duties DWC AD 10133.33 - California
| Description Of Employees Job Duties Form. This is a California form and can be used in General Workers Comp . |
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State of California Division of Workers' Compensation Retraining and Return to Work Unit DESCRIPTION OF EMPLOYEE'S JOB DUTIES DWC-AD 10133.33 INSTRUCTIONS: This form shall be developed jointly by the employer and employee and is intended to describe the employee's job duties. The completed form will be reviewed to determine whether the employee is able to return to work. EMPLOYEE NAME: EMPLOYER NAME: JOB TITLE: (LAST) (FIRST) JOB ADDRESS: HRS. WORKED PER DAY: HRS. WORKED PER WEEK: (M.I.) CLAIM#: DESCRIPTION OF JOB RESPONSIBILITIES: (DESCRIBE ALL JOB DUTIES) Please check one: Regular Duty Modified Duty Alternative Work 1. Check the frequency of activity required of the employee to perform the job. ACTIVITY (Hours per day) Sitting Walking Standing Bending (neck) Bending (waist) Squatting Climbing Kneeling Crawling Twisting (neck) Twisting (waist) Hand Use: Dominant hand Right--Left--Is repetitive use of hand required? Simple Grasping (right hand) Simple Grasping (left hand) Power Grasping (right hand) Power Grasping (left hand) Fine Manipulation (right hand) Fine Manipulation (left hand) Pushing & Pulling (right hand) Pushing & Pulling (left hand) Reaching (above shoulder level) Reaching (below shoulder level) Keyboarding with both hands DWC AD form 10133.33 (SJDB) Effective 1/2013 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com NEVER 0 hours OCCASIONALLY up to 3 hours FREQUENTLY 3 - 6 hours CONSTANTLY 6 - 8+ hours 2. Please indicate the daily Lifting and Carrying requirements of the job: Indicate the height the object is lifted from floor, table or overhead location and the distance the object is carried . LIFTING Never 0 hrs Occasionally up to 3 hrs Frequently CARRYING Constantly 6-8+ hrs. Height Never 0 hrs. Occasionally Frequently up to 3 hrs. 3-6 hrs. Constantly 6-8+ hrs. Distance 3-6 hrs. 0-10 lbs. 11-25 lbs. 26-50 lbs. 51-75 lbs. 76-100lbs. 100+ lbs. Describe the heaviest item required to carry and the distance to be carried:______________________________________ __________________________________________________________________________________________________ 3. Please indicate if your job requires: YES 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. Employee Comments: NO (IF YES, PLEASE BRIEFLY DESCRIBE) ______________________ ______________________ ______________________ ______________________ _______________________________ ______________________ ______________________ ______________________ ______________________ __________________________ Employer Comments: EMPLOYER CONTACT NAME: EMPLOYER REPRESENTATIVE SIGNATURE: EMPLOYEE'S SIGNATURE: EMPLOYER CONTACT TITLE: DATE: DATE: DWC AD 10133.33 (SJDB) Effective 1/2013 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
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