Case number: .us



Employee: |      |House: |      | |

|Modified start date: |      |Release date: |      |

| | | | |

Questions to ask when gathering modified work assignments information:

| |Specify doctors restrictions: |      |

| | |      |

| | |      |

| |Do you have lifting restrictions: |Yes No Weight limitation:      |

| |Can you walk up/down stairs: |Yes No |

|Office skills |Be specific: |

|Basic office skills |a. |Do you have filing skills (alpha and numerical)? |Yes | |No | |

| |b. |Do you have phone / receptionist skills? |Yes | |No | |

| |c. |Do you have VISA (SPOTS) Card reconciliation experience? |Yes | |No | |

| |d. |Do you have Petty Cash reconciliation experience? |Yes | |No | |

| |e. |Mail sorting? Yes No Copy machine experience? |Yes | |No | |

| |

|Computer skills |Yes No |

| |

|Computer programs used |a. |MS Word experience |Yes | |No | |

| |b. |Excel / spread sheet experience |Yes | |No | |

| |c. |Access |Yes | |No | |

| |d. |OTHER:       |

| |

|Organizational skills: |a. |Supply room sorting/organizational skills? |Yes | |No | |

| |b. |Experience setting up conference calls? |Yes | |No | |

| |c. |Experience setting up meetings via GroupWise? |Yes | |No | |

| |d. |Experience writing or preparing desk manuals? |Yes | |No | |

| |

|OTHER: |a. |      |

| |b. |      |

| |

NOTE: All modified workers are required to sign a confidentiality agreement regarding SOCP Central Office work.

Attire is business casual with work hours 8 a.m. to 5 p.m. A 1 hour lunch or when needed ½ hour is approved to allow for doctor’s appointments.

|Employee Signature: | |Date: |      |

Remember all SOCP Central Office support staff duties and files are confidential.

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