Employers Job Description (F252-040-000)



Department of Labor and IndustriesPhysician billing codes for Review of Job Analysis and Job Description:1038M – Limit one per day1028M – Each additional reviewEmployer’s Job Description Form FORMCHECKBOX Job of Injury FORMCHECKBOX Permanent Modified FORMCHECKBOX Light Duty/TransitionalWorker Name: FORMTEXT ?????Claim Number: FORMTEXT ?????Company Name: FORMTEXT ?????Job Title: FORMTEXT ?????Phone Number: FORMTEXT ?????Fax Number: FORMTEXT ?????Hours per day: FORMTEXT ?????Days per Week: FORMTEXT ?????Essential Job Duties: FORMTEXT ?????Machinery, Tools, Equipment, and Personal Protective Equipment: FORMTEXT ?????Frequency Guidelines:N: Never (not at all)S: Seldom (1 – 10% of the time)O: Occasional (11 – 33% of the time)F: Frequent (34 – 66% of the time)C: Constant (67 – 100% of the time)Physical Demands:Frequency:Description of Task:Sitting FORMTEXT ????? FORMTEXT ?????Standing FORMTEXT ????? FORMTEXT ?????Walking FORMTEXT ????? FORMTEXT ?????Heights/Ladders/Stairs FORMTEXT ????? FORMTEXT ?????Twisting at the Waist FORMTEXT ????? FORMTEXT ?????Bending/Stooping FORMTEXT ????? FORMTEXT ?????Squatting/Kneeling FORMTEXT ????? FORMTEXT ?????Crawling FORMTEXT ????? FORMTEXT ?????Reaching Out FORMTEXT ????? FORMTEXT ?????Talking/Hearing/SeeingLRB FORMTEXT ????? FORMTEXT ?????Working Above Shoulders FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Handling/Grasping FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Fine Finger Manipulation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Foot Controls FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Driving FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Repetitive Motion FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Vibratory TasksH FORMCHECKBOX L FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Lifting ( FORMTEXT ?????) lbs. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Carrying ( FORMTEXT ?????) lbs. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Pushing/Pulling ( FORMTEXT ?????) lbs. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ????? FORMTEXT ?????Comments/Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Employer Name (Please Print)Title FORMTEXT ?????Employer SignatureDateFor Healthcare Providers’ Use OnlyApproval FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Approved with ModificationsHours per Day: FORMTEXT ?????Days per Week: FORMTEXT ?????Effective Date: FORMTEXT ?????If no, please list the objective medical finding: FORMTEXT ?????If approved with modifications, describe the modifications needed: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Healthcare Provider Printed NameHealthcare Provider’s SignatureDate ................
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