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BACK ABOARD
What is it?
Injuries are a terrible reason to miss work for an employee. Your employees have special talents
and skills that they bring to the workplace to facilitate the operations of your business. At
Normandy Harbor Insurance, we know that your employees are a valuable part of your business
and that their absence costs your organization money and productivity.
When a workplace injury occurs, the relationship between the employer and the injured worker
changes. Much of the relationship change deals with uncertainty. Employers are uncertain how
they are going to keep the business productivity without the work value of the employee and fear
the potential impact of litigation or insurance cost increases. Employees are uncertain of their
personal health and the security of their job.
Normandy Harbor’s Back Aboard return-to-work program is a tool to eliminate these unknowns
that deteriorate the employer-employee relationship through a communication system to manage
workers’ compensation injuries effectively and quickly get employees back to earning and
employers back to productivity. Just like falling off a boat in the ocean, there is certainty that the
captain will do whatever he can to get you Back Aboard.
Table of contents:
How Workers Compensation Premiums are Calculated
What Workers Compensation Pays
Back Aboard Approach to Cost Control
o
o
o
o
Early Reporting
Medical Treatment
Return to Work
Litigation Avoidance
Step by Step
1.
2.
3.
4.
5.
6.
7.
Program Set Up
a. Return to work policy
b. Medical Provider Arrangement
c. WC Carrier Contact Information
d. Position Descriptions and Light Duty Checklists
Once an Injury Occurs
When an employee is not able to return
When an employee is released for light duty
When an employee is released to full duty
When an employee obtains legal representation
Forms
a. DWC-1 Notice of injury
b. Accident investigation
c. Physician’s Letter
d. Sample Position Description
e. Sample Light Duty Check List
f. Sample Return to Work Job Offer Letter
How Workers’ Compensation Premiums Are Calculated
As an employer, safety has a large part of the success of your business. An unsafe workplace
and workforce can equate to higher operational expenses, poor reputation, and poor employee
morale which can all lead to being less competitive in the market place. Typically the bottom
line is what is most evaluated. Exactly how much money is affected with safety? The easiest
place to look is your workers’ compensation premium and understanding how it is calculated.
Manual Premium: The first factor is in relation to the type of work you perform; the more
dangerous the work the higher the rate. The manual rate is calculated on the classification of the
workers you have and the payroll you apply in each classification. For example, a secretary is
less likely to get hurt therefore the manual rate for that employee may be as low as $0.50 per
$100 of payroll. A welder who works with high voltage electricity, flammable gases, and
overhead hoists may have a rate as high as $12.50 per $100 in payroll. This aspect an employer
has little control over because your business does what it does.
Experience Modification Factor (Multiplier): Experience Modification is something directly
involved with claims costs and frequency. The experience modification is a multiplier to your
insurance premium based on the amount of injuries and claims costs you have incurred in the
past. These are calculated over a 3-year moving average. It basically works like this: If your
workplace has an average amount of claims and costs over the 3-year rated period, your
multiplier will be 1.00. If you have less injuries or less severe injuries with regards to costs over
that period you are considered better than average and less likely to have injuries, therefore your
multiplier will be less than 1.00. If your workplace claims history is poor, your multiplier will be
above 1.00. The following chart illustrates the premium calculation for $100,000 in manual
premium.
Employer Type
Manual Premium
Safe
Average
Unsafe
A
$100,000
$100,000
$100,000
Experience
Multiplier
*B
0.85
1.00
1.35
Actual Premium to
pay
=C
$ 85,000
$100,000
$135,000
As seen in the example, the employer with more claims has an expense that is nearly two times
that of the safe employer. This makes the safe employer much more competitive in pricing and
profitable.
In regards to reputation, injured employees are normally unhappy employees as their physical
and financial well being are in jeopardy while injured. Frequent injuries may scare off good
employees which may result in poorer work performance. Remember, your company is only as
good as the people working for it.
What Workers’ Compensation Insurance Pays
The purpose of work comp insurance is to medically repair the injured worker and return the
worker to full duty without having to go to civil court over the fault of the accident leading to the
injury to determine the benefits or cost. There are three benefits paid for by the insurance
company to an injured worker.
1. Medical Treatment: Workers compensation pays for 100% of the medical cost for the
recovery of an employee until they reach maximum medical improvement and are released from
the treating physicians.
2. Lost Wages/Indemnity: Most states provide a benefit of 2/3rds of the employee’s average
weekly wage if they are unable to work. However, most states do not provide this benefit until
the employees has missed 7 days of work and employees typically do not get paid for the first 7
missed days unless they miss 21.
3. Permanent Impairment Settlement: In the event the employee has a permanent disability as
a result of the workplace accident, the employee will be provided with a settlement based on the
severity of the permanent impairment. This payment is usually included as an indemnity
payment as it reflects future wage earning losses. Litigation costs may also be incorporated as
indemnity.
The frequency of claims and the lack of control of the costs of these benefits will determine your
experience modification and your businesses future insurance premiums.
Remember, insurance has one rule, the more you use it (more claims, more cost of claims)
the more it costs in the future (higher premiums).
Back Aboard Approach to Cost Control
The Back Aboard approach is an early intervention process that dissects the three types of
benefit payments and implement processes to minimize the costs in each of these areas. Before
looking at these benefits, it starts with early intervention.
Early Reporting: When a workplace injury occurs the most important factor is to know about
the event, the injury, and let Normandy Harbor know. There are many issues with a workplace
accident that relate to cost containment that take effect in the first few hours after an injury.
Early reporting can help verify the validity of the injury claim, assure the proper medical
treatment, and expedite the return to work process. Claims should be reported to Normandy
Harbor immediately, but no later than 24 hours after your knowledge of an injury. If the
employee never goes to the doctor, the claim does not impact your insurance rating.
Medical Treatment: As an employer, you pay for the through the insurance premiums for all of
the medical treatment an injured worker receives as a result of work place injury. If you are
ultimately paying for it, you should have your injured workers go to your doctor. It would be a
difficult task for an employer to negotiate all possible medical treatment fees. For that reason,
Normandy Harbor has contracted with a medical network that pre-negotiates rates that are a
fraction of the costs of traditional medical treatment. Most of these medical facilities are walk-in
clinics and urgent care facilities and will provide immediate care for far less than a hospital
emergency room. Hospital Emergency Rooms should only be used if injuries are severe or the
injury occurs after the operational hours of the normal medical clinic
Loss Time: Employers pay employees when they are working. It is not the goal of employers
to pay employees for staying home. Returning injured employees back to gainful employment
and keeping them in their normal work habits is the key for quicker recovery, less life disruption,
and litigation avoidance. The Back Aboard process is designed to obtain medical releases from
physicians and assist employers in re-employing injured workers into valuable and gainful
employment while they recover from their injury. The basis of this process is educating the
physician in what the physical demands of the employee’s job are through the development and
use of position descriptions. Employees receive loss time and indemnity benefits when they are
not working. If they are working, there are no benefits paid.
Litigation Avoidance: The main reason why an employee seeks the assistance of an attorney
after a workers’ compensation injury is because the employee is afraid that they will lose their
job because they were injured. This is according to a claimant attorney during the 1997 Workers
Compensation Annual Conference. Why is this? First, the employee is hurt and may not be sure
if they will ever be healthy enough to work. They realize that if they can’t work, their income is
lost and their way of life is changed. Employees also fear that if they caused the accident, that
their employer will fire them due to the injury. Secondly, once a claim happens, there are several
people that the employee does not know, who get into their business. A claims adjuster, a doctor
who is not their normal doctor, a nurse case manager all contact the employee. These people are
required by law to provide information of the employee’s rights and responsibilities in the
workers’ compensation process that can be very confusing, again pointing the employee toward
legal representation for security. Legal representation is always paid by the insurance company.
The Back Aboard process focuses on maintaining the close, preexisting relationship between the
employee and employer focusing on the trust that each have in each other to work together
through the injury with the goal of return to full employment.
STEP BY STEP PROGRAM SET UP
1. Return-to-Work Policy Statement. The following policy should be implemented and
enforced. The employees should be made aware of this policy upon hire and at least
annually thereafter by memo or by training meeting.
“It is the policy of this company to provide as safe as workplace as possible for its employees.
Unfortunately, accidents and injuries do occur in the workplace. This can disrupt our operations
and disrupt the lives and livelihood of the injured employees. To enable to provide for
employees injured on the job, our company has implemented a light-duty return-to-work
program to provide gainful employment to injured workers while they recover. We will make
every effort possible to assist in providing employment opportunities in conjunction with your
treating physician’s recommendations. Employees are requested to make their best efforts to
provide as much information about their recovery status to us so that we work to getting you
back to full employment and full wages.”
2. Identify Medical Providers. By contacting Normandy Harbor Insurance Company, a list of
network medical providers can be sent to you to know which medical facilities to send your
injured workers. It is recommended that once you select one or two primary urgent care
facilities, that you contact them introducing your business and informing them that you have
a return to work policy for workers compensation and that you would appreciate their
cooperation in returning injured employee to light duty. Inviting the physician to tour your
facility may also be a good idea so that he can observe what your employees are physically
required to do in the job. That may help in his knowledge of the work tasks at your
company. Remember urgent care facilities should take preference over hospital emergency
rooms for minor injuries.
3. Workers Compensation Carrier Contact Information. Normandy Harbor Insurance
Company is your workers’ compensation insurance carrier. Claims can be phoned in and
faxed in using the following numbers. Phone: 1-877-404-6442 fax 1-407-352-5788. Claims
adjusters are assigned to injured employees to pay bills and to monitor the medical treatment.
Do not be afraid to call with questions. The claims adjuster’s interest is to resolve claims as
quickly as possible and help the employee get back to full employment as soon as possible.
4. Develop Position Descriptions and Light Duty Checklists. Position descriptions are the
key to the physician understanding what the job of an injured worker physically entails.
Position descriptions should be developed for all positions in the workplace and kept of file.
These descriptions should include the tools, work environments, and physical demands of the
job. A light duty checklist should also be developed of work tasks in the facility that may not
require much standing, bending, lifting, or climbing. These can be used to provide light duty
work in other departments when an employee’s restrictions for his regular duties are too
severe to allow for any valuable work.
STEP BY STEP - ONCE AN ACCIDENT OCCURS
1. Assist the employee
The most important thing initially is to get the employee medical treatment. When someone gets
hurt, the first thing they react to is the pain and the most important thing on their mind is
eliminating the pain. Proper medical treatment is necessary to ease this concern and start the
recovery process.
Hospitals should be avoided for minor injuries. Hospitals are designed for emergencies.
Although the injured employee might consider his injury an emergency, the triage nurse may
think otherwise. Hospital waits may exceed hours if the employee is not as severe as the most
recent car wreck. Most clinics will provide care within minutes of arrival. Hospitals also charge
extra fees.
To determine proper treatment follow these steps:
a. Determine the extent of the injury. Can the injured employee use a first aid kit to
treat injury? – Direct to first aid.
b. Can the employee walk and can he drive or have a supervisor drive him without
worsening the injury. Send the injured worker to the designated point of entry
medical facility and report claim to you carrier. If a drug-free workplace, ensure
that the facility will test upon arrival.
c. Is the employee unable to move or unconscious. – Call 911
NOTE: ALWAYS ASK THE EMPLOYEE IF THEY THINK THEY NEED TO SEE A
DOCTOR. Assess the injury and direct to the proper medical facility listed below:
For this facility the primary physician is:
If after hours or emergency – 911 or
Clinic name / Dr. Name
Address
City State Zip
Phone number
Hospital Name
Address
City State Zip
Phone number
While the injured work is en route to the physician, call the medical facility and let them know
that you are sending the injured worker. Inform the medical provider that your company offers a
return to work program and that you are faxing the physician the injured workers’ current
position description to assist in his evaluation of the employee’s ability to return to work and a
light duty checklist outlining other duties that you have available.
2.
Report the Accident.
A critical part of claims management is reporting the incident. Claims should be reported
immediately. This will assign a claim number and provide for proper payment in the event of
medical treatment.
Call Normandy Harbor Insurance Company at 1-877-4046442 or fax the Notice of injury form to 1-407-352-5788.
DO THIS THE SAME DAY OF THE ACCIDENT.
If the employee refuses medical treatment or declines – report the claim as a “for information
only claim” and get a claim number, perform the accident investigation. Check up with the
employee every day for the next week to see if the injury needs medical attention, if so, start the
medical treatment process. Conduct the accident investigation to determine factors the led to the
accident.
3. Obtain Medical Status for Return to Work
While the injured work is en route to the physician, call the medical facility and let them know
that you are sending the injured worker. Inform the medical provider that your company offers a
return to work program and that you are faxing the physician the injured workers’ current
position description to assist in his evaluation of the employee’s ability to return to work and a
light duty checklist outlining other duties that you have available.
Company policy requires that employees return work-status form from the physician. The doctor
will have a form that specifies the diagnosis and the ability of the employee to return to work. If
an employee can drive himself to the doctor, more than likely he should be able to return that slip
the same day. The sooner you know the injury status, the sooner you can prepare for the return
to work process.
Follow this procedure while the injured worker is en-route to the medical facility:
a. Send a copy of the Physician’s Letter and the employee’s current position
description.
b. Ask the supervisor or the employee to return a work status note from the physician
and the position description from the physician.
c. Contact your carrier’s claims department with the return to work status and
preliminary diagnosis. At 1-877-404-6442
If the employee can return to work that day, monitor progress – ask the employee at the end of the
shift how he/she feels.
STEP BY STEP – WHEN AN EMPLOYEE IS NOT ABLE TO RETURN TO WORK
1. Employer – Employee Communication: Communication is the key to keeping the
employee interested in returning to work and letting him or her know that you, the
employer, has their best interest at heart. In the event an injured worker is not able to
return to work the same day or the day after the injury, follow the guideline below when
contacting the injured worker.
a. Call the employee the day after the accident. Ask about their health, what the doctor
told them, how they were treated, and if they have any questions. Also inquire when
their next physician’s visit is and place this on your calendar.
b. Offer assistance. Ask if they need someone to pick up their prescription, have someone
drop off their paycheck, or if they need you to call the workers’ compensation insurance
company with any questions. The workers compensation company should have
explained the employee’s rights and benefits. If they have additional questions, offer to
answer or to get answers.
c. If the employees will be out of work, call them at least once per week. Inquire when
their next physician’s appointment is so that you can be prepared for change in the return
to work status.
d. Call them before and after each medical evaluation. Repeating steps a and b above.
e. ALWAYS SAY THESE WORDS AT THE END OF THE CALL: “We hope you
get to feeling better soon. We need you here at work and hope you can come back as
soon as possible.”
2.
Employer- Carrier Communication: After each contact with the employee, it is
important to either call or e-mail the adjuster on any specific issues that may warrant
concern or change the potential of the employee to return to work. This may include, a
statement from the employee on any special medical treatment such as surgery that the
doctor recommended, any statement regarding wage questions or missing indemnity
checks, or any statements indicating that they are ready to return to work or have sought
legal representation. If an employee has a long recovery, these communications should
take place about every 2 weeks.
3.
Employer- Physician Communication: Each physician’s appointment should include
the faxing of the physician letter, current job description, and the light duty tasks list the
day before the employee’s visit. This will keep the physician alert to the evaluation of
the employee’s progress to return to work.
STEP BY STEP – WHEN AN EMPLOYEE IS RELEASED FOR LIGHT DUTY
When an employee is released with restrictions, the largest tasks fall on the employer. The
important part is to obtain the medical restrictions and develop a new position description for the
modified duty including the hours of work, date to report to work, wage to be paid and all of the
tasks you want the employee to do.
1. Employer- Carrier Communication: Upon notification from the physician, employee
or carrier that an employee has been released for light duty, contact the insurance
company to receive the restrictions or documentation provided by the physician. From
this develop a modified duty position description and send a copy to your carrier’s claims
adjuster and inform the adjuster what hours, duties, and wages you are willing to pay for
the light duty work and what date you plan on having that employee start that position.
2. Employer- Physician Communication: Upon completion of the modified duty job
description, fax the description to the physician to ensure that he agrees with the
accommodations to ensure that the work does not put the employee at additional risk of
injury or inhibit the healing process. Follow up the fax with a phone call.
3. Employer- Employee Communication: When the position description is complete and
approved by the physician, call the employee to let them know how excited and happy
you are that you are able to have them back on the job. Let the employee know that they
will receive a job offer and position description for the light duty work that will discuss
their hours, wage rate, and report date as well as the tasks they are limited to do. Inform
the employee of the supplemental benefits paid by insurance if the wages for the light
duty work do not total 80% of the average weekly wage of their full duty position. End
the call with “We are glad that you are getting better and can come back to work
with us. We can’t wait to get you back to your normal job once you’re completely
healthy. Look for our letter, and we’ll see you on the _______ at _____a.m.”
Mail the modified position description and the Light Duty Job Offer letter to the employee 2
ways, 1 by regular first class mail, the second by Certified mail with a Return Receipt
Requested.
STEP BY STEP – WHEN AN EMPLOYEE IS RELEASED FOR FULL DUTY
As an employer, the best news you can receive is that the employee has been released for full
duty and is ready to return to work at his original job.
1. Employer- Carrier Communication: Upon notification from the physician, employee
or carrier that an employee has been released for full duty, contact the insurance company
to inform them of the planned start date for resuming full duty work.
2. Employer- Employee Communication: When you hear of the news, call the employee
to let them know how excited and happy you are to have them back on the job. Let the
employee know that they will receive a job offer and position description for their normal
duty work and provide them with the return to work date and time. Also inform them
that once they are back to full pay, they will no longer receive any loss wage pay benefits
for any time after their full duty start date. End the call with “We are glad that you are
better and that you can help us get things back to normal around here. We’ll see
you on __________.
Mail the full duty position description and the Full Duty Job Offer letter to the employee 2
ways, 1 by regular first class mail, the second by Certified mail with a Return Receipt
Requested.
STEP BY STEP – WHEN AN EMPLOYEE OBTAINS LEGAL REPRESENTATION
When an injured worker obtains legal representation, the communication process changes
significantly. The claimant attorney may or may not notify the carrier of the suit.
1. Employer- Carrier Communication: Upon notification from an employee or the
claimant attorney, contact the claim adjuster immediately and forward any documentation
sent to you from the claimant attorney. The adjuster will contact the attorney and may
have also received the same information. The adjuster will be the primary contact
between you and the claimant attorney. Communications of litigated cases should be
maintained on a bi-monthly basis if there is little activity.
2. Employer- Employee Communication (employee not back to work): This
relationship may be irrevocably broken when the employer is served or contacted by the
claimant’s attorney. If the employee is not at work, maintain the normal process of
communication as outlined in the previous sections until the employee discontinues
participating in the conversation (normally at the advice of his attorney). In the event of
the discontinuation of communications, rely on the adjuster for information from the
claimant attorney.
3. Employer- Employee Communication (employee is back to work): This is the most
difficult relationship to maintain as the employer is in essence being sued by a person
they are providing for. If the employee is back to work on light or full duty release, treat
the employee just as any other employee with one exception, do not speak as an owner or
supervisor in any one-one communications. Always have a third person in any meeting
with the employee if issues such as work performance, attendance, or disciplinary actions
arise. Increase of supervision is often necessary for the protection of your business.
4. The Goals Never Change: One goal is to show the most good will. The other goal is to
make the effort to employ the injured worker. The injured worker does not receive
benefits if he refuses work that his physician states he is able to do and the employer
offers him even if he is represented by legal counsel.
STEP BY STEP – FORMS
•
•
•
•
•
•
DWC-1 Notice of Injury Report
Accident Investigation Report
Sample Physician’s Letter
Sample Return to Work Job Offer
Sample Position Description
Sample Light Duty Checklist
ACCIDENT INVESTIGATIONS
A.
Fatalities
The president and safety coordinator are notified immediately after a fatality has
occurred. The safety coordinator will conduct a thorough investigation as to the
circumstances surrounding the fatality. The safety coordinator must inform OSHA
within 24 hours.
B.
Serious Accidents
The safety coordinator receives copies of the supervisor’s report of accident when the
accident occurs. The foreman will be responsible of making the safety coordinator aware
of the accident. The foreman and safety coordinator will investigate the accident within
24 hours, if possible. Also, the employee will be present to discuss what happened, or at
a later date depending on the gravity of the injury. The purpose of the investigation will
include the following:
1.
The source of the accident; what actually inflicted the injury or damage.
2.
Type of accident or manner in which the person was injured.
3.
Unsafe condition of equipment.
4.
Unsafe act or practice of the person.
5.
Personal factor or reason for the person’s unsafe act or practice.
6.
Action required to prevent reoccurrence.
C.
Minor Accidents
1.
Accidents of this type are investigated directly by the immediate supervisor.
Supervisors should pay close attention so that the injury/accident does not become
a major accident.
Non-Industrial Illness
1.
If an employee suffers from a non-industrial illness, supervisors will advise the
employee if he wishes to go home or to the hospital, should the employee
complain of discomfort.
D.
SUPERVISOR'S ACCIDENT INVESTIGATION REPORT
Employee Name
Date of Accident
Location of Accident
Time of Accident
Occupation of Employee
Injury
Witness
Reviewed by management
Employee’s description of accident.
What acts, failures to act, and/or conditions contributed most directly to this accident?
What are the reasons for the existence of these acts and/or conditions?
What is the plan of action to prevent recurrence?
Supervisor's comments
Investigated by
Date
Reviewed by
Date
Date
Employer
Address
City, State, Zip
TO: Dr. Treating Physician
FR: Employer contact
RE: Return to work policy
This letter is to inform you that the EMPLOYER NAME has a return to work program for
employees who have been injured on the job and are receiving treatment from you.
EMPLOYER NAME employees are a valuable asset to our company. We depend on them to
keep our operations going and keep us profitable. In that, we at EMPLOYER NAME are
committed in returning injured employees back to work so that our operations and the employees
earning capability are maintained.
We care deeply for our employees and see each injury as a personal loss as well as a business
loss. We wish for employees to return to work as healthy as before they left. We are also
concerned for their personal financial situations as injured employees usually see a decrease of
earning potential when not able to come to work.
Attached is the employee’s current position description. This outlines the employee’s job
functions and the physical demands of the job. Please review the description and identify
which functions the employee is capable of performing at this time and what
accommodations may be necessary for this to be maintained. Please fax the modified
position description back to our office at (___)___-_____.
In the event that the employee is not able to perform any functions of his current position, we do
have employment needs in other departments. We would like to provide the position descriptions
of available work so that our employees maintain their earning capability.
We appreciate you participation and assistance in our mutual goal of returning our injured
employee back to health and original work position.
Sincerely,
EMPLOYER CONTACT
JOB TITLE
DATE OF LETTER
Company Name
Company Address
City, State Zip
Injured Employee Name
Address
City, State Zip
Dear Injured Employee Name,
As an employer who is interested in the well being of our employees, we are committed to
providing light duty work for our employees to provide them the opportunity to continue
receiving wages while healing from workplace injuries. Our employees are valuable to our
organization and your absence is a severe interruption to our normal operations. To this end we
are pleased to offer you the following position beginning on Date of Return to Work.
Job title:
Job Description:
Rate of Pay: $X.XX per hour
Report Hours: Days of week, __:__ am - __:__ pm
Attached is the position description that has been approved by your treating physician with the
accommodations and limitations of the work duties. We will ensure that to protect you from reinjury, we will only allow you to perform the work as outlined until the physician determines
that you are healthy enough to return to full duty. Any reduction in hours and wage rates for this
position will be compensated by the workers compensation insurance carrier according to state
law.
If you have any questions, please call me at ___-___-_____. We look forward to having you
back aboard on DATE OF RETURN TO WORK.
Sincerely,
Manager Name
Title
SAMPLE
COMPANY NAME, INC.
POSITION DESCRIPTION
Title:
Cashier
Department: ______
Pay Rate:
$7.50 – $8.00 per hour
Supervisor:
Shift:
Receiving Manager
7:00 am - 3:00 pm
Skill/Education/Experience Requirements: At least 16 years old. Completed at least 8th Grade. Must
be able to read and perform basic addition, subtraction, and multiplication. Must be able to verbally
communicate with customers. Must be able to handle and count money.
Tasks Performed:
• Employee is responsible receiving customer’s orders for food.
• Employee will use a computerized cash register to input orders to the cook line.
• Employee will receive payment from the customers for the items purchased.
• Employee is responsible for assembling the customer’s order from the food warmers, place it in the
proper bags and hand the items to the customer over the counter.
• The employee is also responsible for periodically cleaning up the dining area. This includes
vacuuming carpets, sweeping floors with a broom and dustpan, and placing trash into the provided
trash receptacles.
Equipment Used:
Cash Register, broom, and vacuum cleaner.
Physical Requirement:
Employee must be able to
Walk without assistance
Stand up to 8 hours per day
Walk in lengths up to 20 feet at a time
Lift up to 4-5 lb every 2-5 minutes.
Push and pull a vacuum cleaner
Infrequent bending and stooping.
This position description was reviewed with me prior to my employment in this position and I hereby
certify that I am physically able to perform this job with
1. No accommodations
2. The following accommodations:
_____________________________________________________________________________________
___________________________________________________________
_______________________
_____________________
employee signature
supervisor signature
MODIFIED DUTY CHECKLIST –
Give to Employee to take to
Medical Provider
Please check which of the following assignments can be performed while on modified duty:
OFFICE
______
______
______
______
______
______
______
Answer Phones
Filing
Mail Delivery
General Paperwork
Data Entry
Copying
Faxing
LAUNDRY
______
______
______
______
______
______
______
NURSING
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
RESIDENT CARE
______
______
______
______
______
______
Dietary
______
______
______
______
______
______
______
______
ENVIRONMENTAL SERVICES
Charting
Phone Calls
Vital Signs
Passing Meds
Passing Meds
Pushing Med Cart
Ambulating Residents
Making Beds
Feeding Residents
Passing water
Cleaning Wheelchair
Dressing Residents
Bathing Residents
Oral Care
Shaving
Organize Closets and bed
stands
Set Up Food Trays
Deliver Food Trays
Set Tables
Clean Tables
Load Dishwasher
Stock Food Shelves
Clean Pots and Pans
Mop Floor
Washing Linens
Folding Linen
Stocking Linen Carts
Sorting soiled Linen
Marking Clothing
Mending Clothing
Deliver Residents Clothing
Dusting
Sweeping
Mopping Floors
Cleaning Windows
Painting
ACTIVITIES
Read to Residents
Call Bingo Numbers
Room to Room Visits
Nail Care
Supervise Smokers
Play Music/Show Movie
GENERAL
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Lift Up to 10 Lbs
Lift Up to 20 Lbs
Lift Up to 30 Lbs
List Up to 50 Lbs
Walk
Sit
Push
Bend
Restricted Use of ____ Arm
Restricted Use of ____ Leg
Other__________________
ADDITIONAL COMMENTS:_____________________________________________________
____________________________________________________________________________
PATIENT NAME:_____________________________________________________________
DR. SIGNATURE:____________________________
DATE:____/____/______