Job Analysis {WC-240A}

WC-240a JOB ANALYSIS GEORGIA STATE BOARD OF WORKERS' COMPENSATION JOB ANALYSIS Instructions: File this form as an attachment to a WC-240 Board Claim No. Employ ee Last Name Employ ee First Name M.I. SSN or Board Tracking # Date of Injury Name Contact Person EMPLOYER Job Title Position Telephone Number Prepared by: Date: SCHEDULE Shift(s): Days: Self-Paced? WORK PACE Incentive Based? Machine Paced? Yes Hours / Week: Overtime: Rate of Pay: No Yes No Yes No Production Standards (Define Requirements): JOB DESCRIPTION (What is the purpose and objective of this job?): WEIGHT LIFTING Negligible 10 lbs. Max. 20 lbs. Max. 25 lbs. Max. 50 lbs. Max. 100 lbs. Max. Over 100 lbs. FREQUENCY Never Occasional (up to 1/3 of the time) Frequent (1/3 to 2/3 of the time) Constant (over 2/3 of the time) OBJECTS Low est Point Lift/Low er Height Highest Point Lift/Low er Height CARRYING Negligible 10 lbs. Max. 20 lbs. Max. 25 lbs. Max. 50 lbs. Max. 100 lbs. Max. Over 100 lbs. Max. Distance Carried PUSH/PULL MAX FORCE Negligible 10 lbs. Max. 20 lbs. Max. 25 lbs. Max. 50 lbs. Max. 100 lbs. Max. Over 100 lbs. Max. Distance Moved -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-240a REVISION . 07/2011 240a 1 OF 2 JOB ANALYSIS American LegalNet, Inc. www.FormsWorkFlow.com WC-240a JOB ANALYSIS GEORGIA STATE BOARD OF WORKERS' COMPENSATION POSTURES / MOVEMENTS Sitting Standing (in place) W alking Use Arm/Leg Controls MAX. CONSEC. MIN/HOURS TOTAL DAILY HOURS POSITION CHANGE OPTIONAL? FURTHER DESCRIPTION Never Bending Turn/Twisting Kneeling Squatting Crawling Climbing Reaching (out) Reaching (up) W rist Turning Grasping Pinching Finger Manipulation Occasional (up to 1/3 of the time) Frequent (1/3 to 2/3 of the time) Constant (over 2/3 of the time) LIST EQUIPMENT, MACHINES, TOOLS, VEHICLES USED SPECIAL CONSIDERATIONS (ENVIRONMENTAL CONDITIONS, VISION, HEARING, HEIGHT) Employer's Signature (Title) Date TO BE FILLED OUT BY THE AUTHORIZED TREATING PHYSICIAN 1. 2. 3. 4. Employee can perform this job w hile taking medications as prescribed I do release the employee to the job described I do not release the employee to the job described Yes No I only release the employee to the job described w ith the follow ing restrictions/limitations/modifications: Physician's Name Physician's Signature Date -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-240a REVISION . 07/2011 240a 2 OF 2 JOB ANALYSIS American LegalNet, Inc. www.FormsWorkFlow.com