Job Description Template

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JOB DESCRIPTION
REGULAR
MODIFIED
EMPLOYER:
Oregon Military Department
WORKER:
ADDRESS:
ATTN: AGP
ADDRESS:
PO Box 14350-AGP
Salem, OR 97309-5047
PHONE/FAX NUMBER:
(503) 584-3581 / (503) 584-3556
PHONE NUMBER:
CONTACT PERSON:
Robin Webb
CLAIM NUMBER:
WORKERS JOB TITLE:
HOURS PER
DAY/WEEK:
JOB DUTIES (attach narrative description if available, complete physical requirements below):
Functions performed:
ENDURANCE
Never
Intermittent <1 hr
Occas. 1-3 hrs
Freq. 3-6 hrs.
Continuous 6+ hrs.
Total Hours in a work day
Sitting
Standing
Walking
PHYSICAL REQUIREMENTS
Intermittent
Intermittent
Lift
0 hr
Occas.
Freq.
Cont.
0
Occas.
Freq.
Cont.
<1 hr
<1 hr
1-3
3-6 hrs.
6+
hr
1-3 hrs.
3-6
6+
hrs.
hrs
hrs.
hrs
1-10 lbs
Bend
11-20 lbs
Twist
21-50 lbs
Crouch
51-75 lbs
Kneel
76-100 lbs
Crawl
Walk-Level Surface
Carry
Walk-Uneven Surface
1-10 lbs
Climb Stairs
11-20 lbs
Climb Ladder
Reach Above Shoulder
21-50 lbs
51-75 lbs
Use of Arms
Use of Wrist
76-100 lbs
Use of Hands
Push
(a) Grasping
1-10 lbs
(b) Squeezing
11-20 lbs
Operate Foot Control
21-50 lbs
51-75 lbs
Environment
76-100 lbs
Inside
Pull
Outside
1-10 lbs
Heat
11-20 lbs
Cold
21-50 lbs
Dusty
51-75 lbs
Noisy
76-100 lbs
Other
ADDITIONAL COMMENTS:
Employer Signature:
Employee Signature:
Employer Contact Title/Date:
Date:
FOR PHYSICIAN TO COMPLETE:
Is this job appropriate?
Yes
No
Date of Release: _________________
If not released to regular work at this time, please provide an “ANTICIPATED” DATE: _____________________
Physician’s Signature:
Date:
AGP Form WC-101
4/1/08
Attchmt to AGP Policy 99.100.06

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