SUMMARY OF LIMITATIONS



Physicians Assessment for Work

Capabilities

Wal-Mart Stores

Associate Name________________________________________ Today’s Date__________________________

PHYSICIAN FINDINGS

Released to Return to Work: Regular Duty Modified (Temporary Alternative Duty) as of ________________________

What are the physical capabilities: (at home or work) _______________________________________________________________

All limitations should apply to the work place or activities of Daily Living

Can the associate continue in their current job? ____________ If no, what accommodation would allow them to continue in their current position__________________________________________________________

Other physical limitations (bending, standing, stooping, reaching, etc.)__________________________________________________

Special Instructions__________________________________________________________________________________________

If the associate CAN NOT stay in their current position please check which positions you recommend below.

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If associate is unable to perform in any of the above positions, what additional restrictions could enable the associate to return to work?

_________________________________________________________________________________________________________

_____ Associate is currently unable to return to work on any basis because_____________________________________________

Physician’s Signature_____________________________________________________ Date______________________________

Store Manager’s Signature_________________________________________________ Date______________________________

Associate’s Signature_____________________________________________________ Date______________________________

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FACILITY MANAGER: Review the limitations and jobs approved by the physician with the worker. You and the worker sign and date this form. Please retain the original in the associates workers compensation file and give a copy to the worker.

Next Appointment:

|Overnight Processor | |Signing Clerk |

|Unpacks, processes, and displays soft lines merchandise. Prepares | |Checks signage for accuracy. Places and removes shelf and other |

|garments for hanging; involving grasping, turning, and manipulating | |signage. Frequent walking, pushing, pulling, reaching and lifting and |

|objects. Continuous standing, bending, reaching and lifting up to 1lb. | |carrying up to 1lb. Occasional crouching, standing, stooping, and |

| | |kneeling. |

|Zoning – Parking lot | |Zoning – Merchandise on Sales Floor |

|Moves through lot ensuring safety, customer service, and light cleanup. | |Moves through sales floor to pull product forward on shelves and |

|Continuous walking. Frequent manipulation of objects. Occasional | |straighten up. Continuous walking and manipulation of objects. |

|standing, stooping and reaching below shoulder or knee level. | |Frequent pushing/pulling, reaching, and lifting to 5lbs. Occasional |

|Occasional lifting/carrying up to 2lbs. | |stooping, kneeling, standing and crouching. |

|People Greeter (Entrance, Exit, Garden) | |Operator - Fitting Room |

|Greets customers at doors, deactivates security tags, facilitates | |Answers telephone, visually monitors fitting rooms. Intermittently |

|returns, checks receipts and provides generalized customer service. | |hangs/re-tags clothing. Continuous manipulation of objects. |

|Frequent to continuous standing/walking, lifting to 6lbs., and | |Intermittently re-hangs/tags cloths. Frequent sitting, below-shoulder |

|manipulating of objects. Can accommodate occasional intermittent | |reaching. Occasional standing, walking pushing, pulling, stooping and |

|sitting. | |above-shoulder reaching. Lift up to 5lbs. |

| |Cashier (self-checkout) | |Other |

| |Monitor up to four self checkout stations. Frequent standing and | |(Please describe in detail the TAD position available) |

| |manipulation of objects. Occasional walking, stooping, crouching, | | |

| |below-shoulder reaching and lifting up to 10lbs. Can accommodate up| | |

| |to frequent sitting on an intermittent basis. | | |

Next Appointment:

ATTENTION PHYSICIAN:

• Send one copy to your local Wal-Mart or Neighborhood Market

• Mail one copy to PO Box 1288 Bentonville, AR 72712

• Retain one copy for your records

FACILITY MANAGER: Review the limitations and jobs approved by the physician with the worker. You and the worker sign and date this form. Please retain the original in the associates workers compensation file and give a copy to the worker.

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