Ohio > Workers Comp > Medical Providers
DEP Physicians Report To Work Ability BWC-1270 - Ohio
| DEP Physicians Report To Work Ability Form. This is a Ohio form and can be used in Medical Providers Workers Comp . |
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BetterWorkersCompensation DEPPhysicians Builtwith youinmind. ReportofWorkAbility INSTRUCTIONS: Thisformisnowavailableonlineat: Completethefollowingitemsbasedonyourclinicalevaluationandother www.ohiobwc.com testingresultsoftheinjuredworkerperaneight-hourworkday. Checkapropriateboxesasyouarecompletingthisform. Injuredworkername Claimnumber SSNifclaimnumberunknown Dateofinjury // Injuredworkeroccupation Employername Work/Non-WorkCapabilities %ofWorkday(8hr) Noneatall Occasional Frequent Continuous Repetitionsperhr 0% 1-33% 34-66% 67-100% 4-6 6-12 >12 Lift/Carry Upto10lbs..................................... 11-20lbs......................................... 21-50lbs......................................... 51-100lbs....................................... Bending.......................................... Twist/turn....................................... Reachbelowknee............................. Push/pull........................................ Squat/kneel..................................... Stand/walk...................................... Sit.................................................. Liftingaboveshoulders...................... HandrLeftRiestrictionsght NouseoLeftRif ght Mustwearsplint Arm Noliftinggreaterthan_______lbs Hand Norepetitiveactivities Finger______ CTIVITYORKAW Noworkwithhotorcoldsubstances Other___________________ Aretherestrictions temporary permanent Iftemporary,giveanopinionastotheexpecteddurationoftherestrictions:from__________to__________ Duetotherestrictionsnotedabove,howmanytotalhoursperdayandperweekistheinjuredworkerabletowork? ________Hours________Days Physiciansfurtherexplanationofworkabilitiesorwhytheinjuredworkerisunabletoperformanywork: Icertifythattheaboveinformationiscorrecttothebestofmyknowledge.Iamawarethatanypersonwhoknowinglymakesafalsestate - ment,misrepresentation,concealmentoffactorany otheractoffraudtoobtainpaymentasprovidedbyBWCorwhoknowinglyaccepts paymenttowhichthatpersonisnotentitled,issubjecttofelonycriminalprosecutionandmay,underappropriatecriminalprovisions,be punishedbya?ne,imprisonment,orboth. Physiciansignature Date (mandatory) // BWC-1270(6/2/2004) C-143 American LegalNet, Inc. www.USCourtForms.com
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