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Job Analysis/Work Recommendations

NOTICE TO PHYSICIAN: We have a Return to Work Program because there are many benefits to returning our injured employees to work as soon as possible following injury. Please provide the following information to help us determine if suitable, modified work is available, based on your specific recommendations

WORKER: *

JOB TITLE: *

EMPLOYER:

DPR Construction

PHONE NUMBER:

916.418.1910 / 916.826.9996

ADDRESS:

2480 Natomas Park Drive, Suite 100 Sacramento, CA 95833

FAX NUMBER:

916.568.0269

CONTACT PERSON:

Heidi Rodriguez

DURATION:

Up to 14 days – subject to periodic review

JOB DUTIES: *

PHYSICAL WORK REQUIREMENT / TEMPORARY PHYSICAL ABILITIES (No comment means no restrictions)

Physical

Lift	Never 0 %	Occasional 33%	Frequent 45-66%	Continual 67-100%
1 to 10 pounds
11 to 20 pounds
21 to 50 pounds
51 to 75 pounds
76 to 100 pounds

	Never 0 %	Occasional 33%	Frequent 45-66%	Continual 67-100%
Bend
Twist
Crouch
Kneel
Crawl
Walk-Level Surface
Walk-Uneven Surface
Climb Stairs
Climb Ladder
Reach Above Shoulder
Use Arms
Use Wrists
Use Hands
(a) Grasping
(b) Squeezing
Operate Foot Control

Carry

1 to 10 pounds
11 to 20 pounds
21 to 50 pounds
51 to 75 pounds
76 to 100 pounds

Push

1 to 10 pounds
11 to 20 pounds
21 to 50 pounds
51 to 75 pounds
76 to 100 pounds

Pull

1 to 10 pounds
11 to 20 pounds
21 to 50 pounds
51 to 75 pounds
76 to 100 pounds

Environment

Inside
Outside
Heat
Cold
Dusty
Noisy
Other

Length of time anticipated at these limitations?

Date of anticipated MMI/P&S?

Physician’s Comments:

Physician’s Signature:

Clear signature

Date:

Employer’s Represent-ative Signature:

Clear signature

Date:

Employee’s Signature:

Clear signature

Date: