Request For Job Description
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1
2Request for Job Description
Injured Worker Name
In order for the Bureau of Worker’s Compensation to manage the disability of the above-
mentioned injured worker, a description of their regular duty job is required. If your company
has a formalized job description, please forward a copy to the Claims Service Specialist (CSS)
listed at the bottom of this questionnaire.
If a formalized job description does not exist, please complete the questions below and return this
completed questionnaire to the CSS listed at the bottom. Please contact the CSS if you have any
questions. Thank you for your time in completing this job description questionnaire.
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Occupation/Job Title
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Primary Duties
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Secondary Duties
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Does the injured worker drive or operate machinery? Please describe.
Are you able to provide modified duty for this injured worker?
Yes
No
Possibly
(circle one)
Please circle the physical requirements of the injured worker's job.
Lifting Requirements
Up to 5lbs
Never
Occasionally
Frequently
Continuously
6 to 10 lbs
Never
Occasionally
Frequently
Continuously
11 to 20 lbs
Never
Occasionally
Frequently
Continuously
21 to 25 lbs
Never
Occasionally
Frequently
Continuously
26 to 50 lbs
Never
Occasionally
Frequently
Continuously
51 to 100 lbs
Never
Occasionally
Frequently
Continuously
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Parent category: Business