Employers Job Description {F252-040-000}

Department of Labor and Industries Physician billing codes for Review of Job Analysis and Job Description: 1038M ­ Limit one per day 1028M ­ Each additional review, up to 5 per worker per day. Employer's Job Description Form Job of Injury Permanent Modified Light Duty/Transitional Claim Number: Job Title: Fax Number: Days per Week: Worker Name: Company Name: Phone Number: Hours per day: Essential Job Duties: Machinery, Tools, Equipment, and Personal Protective Equipment: Frequency Guidelines: N: Never (not at all) F: Frequent (34 ­ 66% of the time) Physical Demands: Sitting Standing Walking Heights/Ladders/Stairs Twisting at the Waist Bending/Stooping Squatting/Kneeling Crawling Reaching Out Talking/Hearing/Seeing Working Above Shoulders Handling/Grasping Fine Finger Manipulation Foot Controls Driving Repetitive Motion Vibratory Tasks H L Lifting ( ) lbs. Carrying ( ) lbs. Pushing/Pulling ( ) lbs. Comments/Other: S: Seldom (1 ­ 10% of the time) O: Occasional (11 ­ 33% of the time) C: Constant (67 ­ 100% of the time) Frequency: Description of Task: L RB Employer Name (Please Print) Title Employer Signature Date For Healthcare Providers' Use Only Approval Hours per Day: Yes No Approved with Modifications If no, please list the objective medical finding: If approved with modifications, describe the modifications needed: Days per Week: Effective Date: Healthcare Provider Printed Name Healthcare Provider's Signature Date American LegalNet, Inc. www.FormsWorkFlow.com F252-040-000 Employer's Job Description Form 05-2016