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Job Analysis For Worksite Modification - Attachment A 1930a - Oregon
| Job Analysis For Worksite Modification - Attachment A Form. This is a Oregon form and can be used in Preferred Worker Program Workers Comp . |
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OREGON Job Analysis for Worksite Modification Workers Compensation Division Attachment A If you have questions or need further assistance, please contact the Preferred Worker Program in Salem, (503) 947-7588; toll-free in Oregon, (800) 445-3948; fax (503) 947-7581; TTY (503) 947-7993. Worksite information Workers name: WCD no.: Employer: Current job title: When answering the following, attach a separate sheet of paper if necessary. Describe the workers job duties: What are the workers injury-caused limitations? If not know, put unknown. Note: The program will verify permanent limitations before approving any worksite-modification purchases. List the job duties that are beyond the workers injury-caused limitations: 1. 2. 3. 4. What modification(s) will allow the worker to do the job within the permanent restrictions? If not known, put unknown. 1. 2. 3. 4. To the best of our knowledge, this information is true and correct. Worker signature Date Employer signature Date 440-1930a (3/02/DCBS/WCD/WEB)
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