SUMMARY OF LIMITATIONS



Physicians Assessment for Work

Capabilities

Distribution Centers

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:

|Order Filling Associate | |Quality Assurance Associate |

|Researching discarded label backings, Searching out strays and cleaning. | |Verifies inventory, use walk/ride stock picker. Occasionally lift/carry, |

|Occasionally lift/carry, push/pull up to 10lbs. Frequent bending, twisting, | |push/pull up to 10lbs. Frequent bending, twisting squatting, reaching and |

|squatting, reaching and manipulating objects | |manipulating objects. |

|Custodian | |System Operator Associate |

|Maintains housekeeping standards and cleans assigned areas. Frequently | |Uses computer to process bill/enter data. Frequent lift/carry, push/pull up to|

|lift/carry, push/pull up to 10lbs and up to 20lbs. Frequent bending, twisting, | |10lbs., bending, twisting, squatting, stooping, reaching and fine |

|squatting. | |manipulations. |

|Label Control Associate | |Label Backing Auditor |

|Mostly sitting position, no lifting over 5lbs. Separating labels and | |Sitting position, no lifting. Sorting used orderfilling label backings in |

|sorting them to a specific order for orderfilling associate use | |order to verify all labels have been used in the orderfilling process. |

|Traffic Clerk Associate | |Other (Please describe in detail the TAD position available) |

|Performs various office duties including maintaining logs, records, and forms. | | |

|Occasional lift/carry, push/pull up to 10lbs. Frequent bending, twisting and | | |

|squatting. | | |

| | | |

ATTENTION PHYSICIAN:

• Send one copy to your local Distribution Center

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

• Retain one copy for your records

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