Form Ucb-474 - Medical Report To Determine Unemployment Insurance (Ui) Eligibility Page 2
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6IV. GENERAL ABILITY TO WORK
As of
was the claimant able to work?
(Check all that apply)
No. Claimant cannot work due to the medical condition(s) reported on this form.
Yes. Claimant may work, but must limit the activities and/or hours of work. (COMPLETE SECTION V.)
_____________________________________ is the date the claimant was/will be able to return to full-time (35 or
more hours per week) work without restrictions.
Yes. Claimant is able to work full time without restrictions.
V. RESTRICTIONS
A. Check one of the following classifications of work that the claimant is able to perform:
Sedentary Work. If the claimant is restricted to lifting, carrying, pushing or pulling less than 10 pounds, or is required to
sit most of the time and can only walk or stand occasionally, then s/he is available for sedentary work only.
Light Work. If the claimant is restricted to lifting, carrying, pushing or pulling not more than 20 pounds occasionally,
and/or to 10 pounds frequently; or is not to walk or stand to a significant degree, but is suppose to sit most of the time, then
s/he is available for light work only. If the claimant cannot use arm or leg motions, or use a hand or a foot to a significant
degree, then the claimant is available for light work.
Medium Work. If the claimant is restricted to lifting, carrying, pushing or pulling not more than 50 pounds, and/or is
restricted to 20 to 50 pounds occasionally; then s/he is available for medium work. A claimant who is available for medium
work would have no restrictions regarding walking or standing.
Heavy Work. If the claimant is restricted to lifting, carrying, pushing or pulling not more than 100 pounds, and/or is
restricted to 25 to 50 pounds frequently; then s/he is available for heavy work. There would be no restrictions regarding
walking or standing.
Very Heavy Work. There are no restrictions regarding very heavy work.
Check all categories of activities that apply to the claimant
CAN PERFORM
CAN PERFORM
NO
ACTIVITY
OCCASIONALLY
FREQUENTLY
RESTRICTIONS
MUST BE
1 to 33%
34 to 67%
AVOIDED
Stooping
Climbing
N/A
Crouching
N/A
Crawling
N/A
Kneeling
N/A
ACTIVITY (degree of ability)
Balancing
Must not be relied on
No restrictions
Reaching
Must not extend hand and arms
Limited to 1/3 normal reaching ability
Limited to 2/3 normal reaching ability
No restrictions
Fingering (picking, pinching,
Or fingering activities)
Must be avoided
Limited to 1/3 normal dexterity
Limited to 2/3 normal dexterity
No restrictions
B. Indicate how many hours the claimant can work per week based on the restrictions listed on this form or for other medical reasons.
0 to 17 hours
18 to 23 hours
24 to 29 hours
30 to 34 hours
35 or more hours
UCB-474ho (R. 10/99)
3.28
April 2000
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