Appendix U

RETURN-TO-WORK PROGRAM
TEMPORARY ASSIGNMENT JOB DESCRIPTION
Employee Name: __________________      Hosting Department/Location: _________
 
Position Name: ____________________     Effective Date: _______________________
 
Essential Functions: (Health Care Provider: Indicate if the employee can/cannot perform the essential function listed by circling yes or no.   Supervisor: List essential job functions.)
            ______________________________________________________       Yes       No
            ______________________________________________________       Yes       No
            ______________________________________________________       Yes       No
            ______________________________________________________       Yes       No
            ______________________________________________________       Yes       No
            ______________________________________________________       Yes       No
            ______________________________________________________       Yes       No
            ______________________________________________________       Yes       No
 
Physical Requirements: ( Supervisor: Check those that apply to job described above.   Health Care Provider: Check yes or no)
 
Requirements
Yes
No
Requirements
Yes
No
___ Lifting                         ___ Walking    ___ ___
         ___ Moderate (15-45 lbs) ___ ___ ___ Standing ___ ___
         ___ Light (up to 15 lbs) ___ ___ ___ Sitting ___ ___
___ Carrying     ___ Crawling ___ ___
        ___ Heavy (45 lbs and up) ___ ___ ___ Twisting ___ ___
        ___ Moderate (15-45 lbs)  ___ ___ ___ Pushing ___ ___
        ___ Light (up to 15 lbs) ___ ___ ___ Stooping ___ ___
___ Reaching above shoulders ___ ___ ___ Kneeling ___ ___
___ Straight pulling ___ ___ ___ Ability to read ___ ___
___ Pulling hand over hand ___ ___ ___ Ability to type ___ ___
___ Dual simultaneous grasping ___ ___  ___ Ability to write ___ ___
___ Operating mechanical equipment     ___ Hearing ___ ___
          Specify______________ ___ ___ ___ Speaking ___ ___
___ Operating office equipment     ___ Climbing stairs ___ ___
          Specify______________ ___ ___ ___ Simple grasp ___ ___
___ Operating a motor vehicle ___ ___ ___ Repeated bending ___ ___
___ Other:_________________  ___ ___      
 
Additional Recommendations/Restrictions: (Health Care Provider: List if applicable)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
 
Health Care Provider Signature: _______________________    Date: _______________
Health Care Provider Printed Name: ___________________
Approval of Hosting Department: _______________________   Date: _______________

 

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