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Run: Return to Work Program Modified Duty Job Bank Worksheet

Use this worksheet to catalog modified-duty tasks by physical demand so managers can quickly match temporary assignments to return-to-work restrictions. It h...

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Submission Details

Submission Type (required)

Task Title (required)

Department (required)

Effective Date (required)

Submitted By (required)

Task Description

Task Summary (required)

Primary Work Area (required)

Supervision Level (required)

Expected Duration (required)

Additional Notes

Physical Demand Category

Physical Demand Level (required)

Standing Required? (required)

Maximum Lifting Requirement (lbs)

Enter the maximum weight that may need to be lifted during the task.

Repetitive Motion Involved? (required)

Posture Requirements

Work Restrictions Match

Accommodates Lifting Limit? (required)

Accommodates Standing Limit? (required)

Accommodates Repetitive Motion Limit? (required)

Other Restrictions Accommodated

Restriction Match Notes

Review and Approval

Review Status (required)

Reviewer Name

Review Date

Approval or Revision Comments

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