SUMMARY OF LIMITATIONS



Physicians Assessment for Work

Capabilities

Sam’s Clubs

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:

|Demonstration Associate | |Zoning – Parking Lot |

|Demonstrates products and or prepares food samples. Requires continuous| |Moves through lot looking for safety hazards. Continuous standing and |

|standing, frequent use of hands and below- shoulder lifting up to 1lb. | |walking, occasional stooping and reaching. Incidental lifting/carry up|

|Occasional walking and use of fingers to grasp turn and manipulate small| |to 2lbs. |

|objects. Infrequent stooping/crouching and very infrequent lifting up | | |

|to 10lbs. | | |

|Zoning – Merchandise on Sales Floor | |Zoning – Sams Club Café |

|Moves through sales floor looking for safety hazards. Continuous | |Moves through Club Café area looking for safety hazards. Continuous |

|standing and walking, occasional stooping and reaching. Incidental | |standing and walking; occasional stooping and reaching. Incidental |

|lifting < 1lb. | |lifting < 1lb. |

|Sales Associate | |People Greeter – Entrance or Exit |

|Assists customers in locating items, answering questions and monitors | |Greets customers at doors. Presents and offers individual carts to |

|sales floor activities. Continuous waling and standing; frequent | |customers, requires pushing and pulling. Occasional to frequent |

|below-shoulder reaching, manipulation of objects and lifting/carrying to| |lifting up to 6lbs. Standing/walking sitting as prescribed. |

|10lbs. Occasional stooping, crouching, pushing and pulling | | |

| |Membership Desk Associate | |Other |

| |Assists customers in completing membership forms. Frequent | |(Please describe in detail the TAD position available) |

| |standing/walking, below-shoulder reaching, manipulation of objects, | | |

| |and lifting up to 1lb. | | |

Next Appointment:

ATTENTION PHYSICIAN:

• Send one copy to your local Sam’s Club

• 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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