Form 1 - State Of Delaware First Report Of Occupational Injury Or Disease Page 6
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6DELAWARE WORKERS' COMPENSATION
EMPLOYER’S MODIFIED DUTY AVAILABILITY REPORT
DATE:
EMPLOYER:
EMPLOYEE:
IS MODIFIED DUTY AVAILABLE:
Yes
No
EMPLOYER FAX #:
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 02/2009
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