Work Restriction Form
Employee Name_______________________________________________________________
Address: _____________________________________________________________________
City: ________________________________ State: ___________ Zip Code: _______________
Employee Number: ____________________________________________________________
Employee has restrictions: ___Yes ___No
If yes, what is the estimated duration of the restrictions? _______________________________
Restrictions
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Movement & Posture: Please indicate the hours and minutes.
Example
Sit for __2 hours__ at a time for a total of ___8 hours_____ with a __10 min______ break of:
___X_____ standing ____X____ walking ________ sitting
Sit for ________ at a time for a total of ________ with a ________ break of:
________ standing ________ walking ________ sitting
Stand for ________ at a time for a total of ________ with a ________ break of:
________ standing ________ walking ________ sitting
Walk for ________ at a time for a total of ________ with a ________ break of:
________ standing ________ walking ________ sitting
Strength:
Weight in lbs.
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0 – 10
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11 -20
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21 – 50
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51 - 75
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Lift / Carry below waist
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Lift / Carry at waist / chest
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Lift / Carry above shoulder
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Push / Pull
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