Employer'S Form Instructions/definitions Page 2

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DELAWARE WORKERS' COMPENSATION
EMPLOYER'S MODIFIED DUTY AVAILABILITY REPORT
DATE:__________
EMPLOYER:__________________________
FAX#:_____________________________
EMPLOYEE:________________________________________
IS MODIFIED DUTY AVAILABLE: ____ Yes
____ No
IF AVAILABLE, FOR WHAT PERIOD OF TIME: _____ Weeks
_____ Indefinite
JOB TITLE: _________________________________________
JOB DESCRIPTION:___________________________________________________________________
ENVIRONMENT/WORKING CONDITIONS (e.g., Temperature):_________________________________
Hrs. per day job available: (circle minimum and maximum)
8
6
4
2
0
D.O.T. Classification of Work
(Circle one)
Sedentary
Exerting up to 10 lbs. of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull or
otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may
involve walking or standing for brief periods of time.
Light
Exerting up to 20 lbs. of force occasionally and/or up to 10 lbs. of force frequently and/or negligible amount of force
constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work.
Medium
Exerting 20 to 50 lbs. of force occasionally and/or 10 to 25 lbs. of force frequently and or greater than negligible up
to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Light Work.
Heavy
Exerting 50 to 100 lbs. of force occasionally and/or 25 to 50 lbs. of force frequently and/or 10 to 20 lbs. of force
constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
Very Heavy
Exerting in excess of 100 lbs. of force occasionally and/or in excess of 50 lbs. of force frequently and/or in excess of
20 lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Heavy Work.
Definitions:
Occasionally: activity or condition exists up to 1/3 of the time
Frequently: activity or condition exists from 1/3 to 2/3 of the time
Constantly: activity or condition exists 2/3 or more of the time
Work Postures/Positional requirements: Comment as appropriate in the space provided regarding the following Postures/Positions
for the modified duty job available.
Sitting: __________________
Squatting: ______________________
Standing:
______________________________
Crawling: _______________
Walking: ________________________
Climbing: ___________________________________
Driving: ________________
Repeated arm motions: ___________
Bending:
______________________________
Turn/Twist: ______________
Kneeling: _______________________
Foot controls: ________________________________
Reaching up above shoulder: _______________________ __________
Repetitive use of wrist/hands: _____________________
Comments:___________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
EMPLOYER: Date job is available: _________________________________
________________________________________
Comments:___________________________________________________________________________________________
Employer Signature:____________________________________ Date:________________________
PHYSICIAN: I approve the job described above.
( )Yes.
( ) No.
If no, reasons for disapproval/recommended modifications:____________________________________________________
____________________________________________________________________________________________________
Physician Signature:____________________________________ __ Date:___________________________
Physician Name (Please print)______________________________ Certified provider: YES NO
The Health Care Provider/Physician MUST complete his/her portion of this form and SIGN and RETURN it to the
EMPLOYER within fourteen (14) days of the next date of service after the HC Provider/Physician's receipt of the form from
the employer, but not later than twenty-one (21) days from the HC Provider/Physician's receipt off such form.
EMPLOYER FORM
Revised 08/17/2011

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