N.h. Workers' Compensation Task Analysis printable pdf download

N.H. WORKERS’ COMPENSATION TASK ANALYSIS

In compliance with RSA 281-A:23-b, the employer with 5 or more employees must provide temporary alternative/

transitional work opportunities to all employees temporarily disabled by a work-related injury or illness.

Task is defined as one of the distinct activities that constitute logical and necessary steps in the performance of a

job. A task analysis, for the purpose of this section, is the evaluation of the physical requirements of each task of a

particular job or work assignment.

Employer ______________________________________

Employee _____________________________________

Telephone # ___________________________________

W.C. Insurer ___________________________________

Employer Address _________________________________________________________________________________

Complete the following information to describe the employee’s job at the time of injury:

Job Title ___________________

Usual Job? Yes ___

No ____

General Description/Purpose ______________

________________________________________________________________________________________________

Department ____________________________________

Supervisor _____________________________________

Description of Tasks (use additional page as needed):

1. _______________________________________________________________________________________________

2. _______________________________________________________________________________________________

3. _______________________________________________________________________________________________

4. _______________________________________________________________________________________________

5. _______________________________________________________________________________________________

Tools & Equipment _________________________________________________________________________________

Describe Special Demands __________________________________________________________________________

________________________________________________________________________________________________

PHYSICAL DEMANDS

Complete the following to show the maximum physical demand for all of the tasks listed above. For example, if Tasks

1 through 4 require no bending but Task #5 requires “occasional” bending, the overall job must be rated as requiring

occasional bending.

JOB REQUIRES:

Continuous Frequent Occasional

maximum lifting/carrying of ______ lbs.

part of day

100%-67% 66%-34%

33%-1%

frequent lifting/carry of _________ lbs.

bending

kneeling

WORK SCHEDULE:

squatting

Number of hours/day _______________

climbing

standing

Number of days/week ______________

walking

Does job require Repetitive Motions? (check if applicable)

sitting

wrist

elbow

shoulder

ankle

reaching

Right

driving

Left

fine motor skills

ATTACH JOB DESCRIPTION IF AVAILABLE

____________________________________

__________________

Completed by

Title

Date

N.h. Workers' Compensation Task Analysis

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