Employee Status Report
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1UNIVERSITY OF OREGON
EMPLOYEE STATUS REPORT
Employee Name: ______________________________________ Date of Next Appointment: ____________________
NOTE: This form may be used to assist the University in providing employees with transitional/modified work and/or
reasonable accommodation. PLEASE DO NOT INCLUDE MEDICAL DIAGNOSIS.
Current Status (check one only):
[ ] Released to regular work without restrictions
Date:_______________________________
[ ] Released to transitional/modified work (indicate restrictions below)
Date:_______________________________
[ ] Not released to any form of work*
Date:_______________________________
*Estimated date of release to work:_____________________
RESTRICTIONS (fill in the blank, check box or circle restrictions for each activity):
In a work day, limitations include: SIT __________ hours; STAND __________ hours;
WALK __________ hours
SIT __________ hours; STAND __________ hours;
WALK __________ hours
At one time, limitations include:
67-100%
34-66%
6-33%
1-5%
0%
Continuously
Frequently
Occasionally
Intermittently
Never
BEND/STOOP
TWIST
CROUCH/SQUAT
KNEEL
CRAWL
CLIMB LADDERS
CLIMB STAIRS
REACH ABOVE SHOULDERS
LIFT, CARRY, PUSH, PULL:
Up to 10 lbs.
11-20 lbs.
21-30 lbs.
31-40 lbs.
41-50 lbs.
51-75 lbs.
76-100 lbs.
Use of Feet:
Operate a Foot Control?
Yes
No
Use of Hands:
Repetitive Action
Simple Grasping
Pushing/Pulling
Fine Manipulation
Right
C
F
O
I
N
C
F
O
I
N
C
F
O
I
N
C
F
O
I
N
Left
C
F
O
I
N
C
F
O
I
N
C
F
O
I
N
C
F
O
I
N
C = Continuously 67-100%
F = Frequently 34-66%
O = Occasionally 6-33%
I = Intermittently 1-5%
N = Never 0%
Is the commute (as a driver or passenger) to work within the physical capacities of the employee?
Yes
No
Estimated time for transitional/modified duty:_______________ Medically Stationary? Yes (date)_________ No ____
Please list any restrictions you believe will be permanent and affect the ability of the employee to perform work:
__________________________________________________________________________________________________
Please list side effects from medication, prescribed for use during work hours, that may impair employee’s ability to safely
perform work tasks:__________________________________________________________________________________
Comments:________________________________________________________________________________________
Print Physician’s Name:____________________________________________ Telephone:_________________________
Physician’s Signature:______________________________________________ Date:_____________________________
Office of Risk Management
University of Oregon
th
677 East 12
Avenue, Suite 400
1260 University of Oregon
Eugene, OR 97403-1260
Telephone: (541) 346-8316 Fax: (541) 346-7008
02/12
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