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Employers Job Description F252-040-000 - Washington
| Employers Job Description Form. This is a Washington form and can be used in Claims Workers Comp . |
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Department of Labor and Industries Billing Codes Review of Job Analysis and Job Description 1038M Limit of one per day 1028M Each additional review, up to five per worker, per day EMPLOYER'S JOB DESCRIPTION Job of Injury Permanent Modified Job Light duty/Transitional Claim # Claimant Job Title Employer Phone # Date Description completed by: Title eEssential task description: (Specify position, location, days a week and hours per day): Machinery, tools, equipment and personal protective equipment. (Please submit MSDS if appropriate.): PHYSICAL DEMANDS: N: Never (not at all) S: Seldom (1-10% of the time) O: Occasional ( 11-33% of the time) Frequency Sitting Standing Walking Driving Lifting ( )lb. Carrying: ( )lb. Pushing/Pulling: ( ) lb. Climbing Stairs/Ladders Bending/twisting at waist Kneeling/squatting Crouching/Kneeling Crawling Reaching above shoulder Repetitive Motion Handling/Grasping Fine Finger Manipulation Talking Hearing Seeing Other F: Frequent (34%-66% of the time) C: Constant (67%-100% of the time) Description of Task Date Effective Date: Employer Signature Employer Name FOR PHYSICIAN USE ONLY Physician Approval No Yes Full-time Part-Time Hours per week If part-time, worker is expected to progress to full-time work by (date) Date Physician Signature Physician Name F252-040-000 employer's job description 07-2012 Index: VOC American LegalNet, Inc. www.FormsWorkFlow.com
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