Supervisor’s Signature Date Appendix F Physician Work-Related Injury/Illness Report PLEASE FAX IMMEDIATELY TO BOTH: Date of Service: <Company Name> Fax: <(999) 999-9999 EMC Insurance Companies (Contact your agent for Patient Name: Fax: branch fax number)> Employer: Notified: Yes No Diagnosis: Is condition work related? Yes No Treatment Plan: Medication(s): Date of most recent examination by this office: / / . The next scheduled visit is: as needed OR / / . Month/Day/Year 1. Recommended his/her return to work with no limitations on . Date 2. He/She may return to work on with the following limitations: Date DEGREE LIMITATIONS 1. In an 8 hour work day, patient may: Sedentary Work. Lifting 10 pounds maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met. 2. Patient may use hands for repetitive: Light Work. Lifting 20 pounds maximum with Single grasping frequent lifting and/or carrying of objects weighing Pushing and pulling up to 10 pounds. Even though the weight lifted may Fine manipulation be only a negligible amount, a job is in this category when it requires walking or standing to a significant degree or when it involves sitting most of the time 3. Patient may use feet for repetitive movement as in operating foot with a degree of pushing and pulling of arm and/or controls: leg controls. Medium Work. Lifting 50 pounds maximum with Yes No frequent lifting and/or carrying objects weighing up to 25 pounds. 4. Patient is able to: Work. Lifting 100 pounds maximum with frequent lifting and/or carrying of objects weighing up to 25 pounds.
Supervisor’s Signature Date Appendix F Physician Work-Related Injury/Illness Report PLEASE FAX IMMEDIATELY TO BOTH: Date of Service: <Company Name> Fax: <(999) 999-9999 Patient Name: EMC Insurance Companies Fax: (Contact your agent for branch fax number)> Employer: Notified: Yes No Diagnosis: Is condition work related? Yes No Treatment Plan: Medication(s): Date of most recent examination by this office: / / . The next scheduled visit is: as needed OR / / . Month/Day/Year 1. Recommended his/her return to work with no limitations on . Date 2. He/She may return to work on with the following limitations: Date DEGREE LIMITATIONS Sedentary Work. Lifting 10 pounds maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met. Light Work. Lifting 20 pounds maximum with frequent lifting and/or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be only a negligible amount, a job is in this category when it requires walking or standing to a significant degree or when it involves sitting most of the time with a degree of pushing and pulling of arm and/or leg controls. Medium Work. Lifting 50 pounds maximum with frequent lifting and/or carrying objects weighing up to 25 pounds. Work. Lifting 100 pounds maximum with frequent lifting and/or carrying of objects weighing up to 25 pounds. 1. In an 8 hour work day, patient may: 2. Patient may use hands for repetitive: Single grasping Pushing and pulling Fine manipulation 3. Patient may use feet for repetitive movement as in operating foot controls: Yes No 4. Patient is able to:
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