Group Retrospective Rating Program. Job Analyses Bank. Updated June Provided in Conjunction with our Group Retro Program Claims Administrator

Transcription

1 Group Retrospective Rating Program Job Analyses Bank Updated June 2016 Provided in Conjunction with our Group Retro Program Claims Administrator Phone: (425) An Association of Not-For-Profit and Mission Focused Senior Living & Care Providers 1495 Wilmington Drive, Suite 340 DuPont, WA Fax

2 Job Analyses Bank Updated June 2016 Table of Contents (Book is in order of job title as listed below) Assistant Site Manager Cashier Community Site Manager Cook/Helper Daycare Worker Dietary Cook Dishwasher Driver Feeder/Bedmaker Home Care Specialist Homemaker Housekeeper Assisted Living Housekeeper Nursing Home Housekeeper Retirement Community Kitchen Aid Laundry Worker Nursing Home Licensed Practical Nurse (LPN) - Wellness Nurse Assisted Living Licensed Practical Nurse (LPN) Primary Care Nursing Home Maintenance Medical Records Clerk Nurse Assistant Certified (NAC) - Nursing Home Nurse Manager Nurses Aid Certified (NAC) Assisted Living Physical Therapy Assistant Receptionist Recreation/Activities/Therapy Assistant Registered Nurse (RN) - Wellness Nurse - Assisted Living Registered Nurse (RN) - Primary Care Nursing Home Residential Service Associate (RSA) - Assisted Living Security Guard Stock Clerk Transitional Work Options Wait Person

3 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Assistant Site Manager DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Assistant Site Manager Brief Job Description/Duties: Assist Site Manager in performing the daily duties and responsibilities related to the successful operation of the property. Assistant Site Managers typically live on-site. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. 20 lbs. 5 lbs. 2 lbs. lbs. Carry lbs. lbs. 5 lbs. 2 lbs. lbs. Push / Pull lbs. 10 lbs. 5 lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

4 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Assistant Site Manager DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Assistant Site Manager DOT Title: Manager, Apartment House SVP: 4 DOT #: Wage: Type of Industry: 731 Real Estate Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Assistant Site Manager DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Assist Site Manager in performing the daily duties and responsibilities related to the successful operation of the property. Assistant Site Managers typically live on-site. Essential Job Functions: Shows prospective tenants apartments and explains occupancy terms. Informs prospective tenants of availability of nearby schools, shopping malls, recreational facilities, and public transportation. Rents or leases apartments, collects security deposit as required, and completes lease form outlining conditions and terms of occupancy when required. Collects rents due and issues receipts. Issues late notices and follows up on delinquencies. Investigates tenant complaints concerning malfunctions of utilities or furnished household appliances or goods, and inspects vacated apartments to determine need for repairs or maintenance. Directs and coordinates activities of maintenance staff engaged in repairing plumbing or electrical malfunctions, painting apartments or buildings, and performing landscaping or gardening work, or arranges for outside personnel to perform repairs. Directs and coordinates the driver and housekeeping. Resolves tenant complaints concerning other tenants or visitors. Training/Preparation Required: High School education and a minimum of one year experience as an Assistant Site Manager or related field; knowledge of or training in LIHT (Section 42) compliance; knowledge of computers and basic software application including Word, Excel, Outlook and where appropriate, property management software (e.g. AMSI); ability to work with other employees and address resident concerns in a professional manner; the ability to comprehend and perform all responsibilities of the position; able to assist in performing the duties of the Site Manager in his/her absence; neat, clean and professional appearance; must be able to communicate effectively in English - both verbal and written; valid driver's license with clean record and operational vehicle. Machine, Tools, Special Equipment, Personal Protective Equipment Used: PC computer, printer, facsimile, copier, standard office supplies, and vehicle. Based on F Page 2 of 6

5 Claimant: Claim No.: Job Title: Assistant Site Manager Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting Sit in on-site office when providing assistance to residents - documenting concerns, answering questions, collecting rents, preparing marketing materials, etc. Sitting occurs in a swivel office chair. Standing Stand when assisting residents with questions and concerns. Standing occurs on carpet, tile, vinyl, asphalt and concrete surfaces. Stand and walk are intermittent throughout the shift with static standing limited to under 5 minutes in duration. Walking Walk when meeting prospective residents and showing the community. Walking occurs on carpet, tile, vinyl, asphalt and concrete surfaces. Stand and walk are intermittent throughout the shift with walking lasting up to 30 minutes when providing tours to prospective clients or hanging notices/flyers. Job Demand Frequency & Weight Activity Description Lifting Typical office supplies, decorations. Carry (Dist.) 10 ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force Carts are used to move larger and heavier items/boxes throughout the property as needed (holiday decorations, large supplies). Open/close drawers and doors. Seldom push cart with supplies. Perform Work on Ladders Climb Stairs Buildings have elevators available, but stairs may be used in emergencies. Twisting Must be able to twist at neck level to check blind spot while driving. Based on F Page 3 of 6

6 Claimant: Claim No.: Job Title: Assistant Site Manager Body Part Injured: DOT Code: Stooping / Bending To reach lower shelves and bottom drawer of filing cabinets - often performed from a seated position. Crouch/kneel can often be used in lieu of bend/stoop at the employee's discretion. Squatting / Kneeling See Stooping/Bending. Crawling Balancing (Left/Right/Both) Reach Waist to Shoulder Can be performed unilaterally or bilaterally. Work Above Shoulders Can be performed unilaterally or bilaterally. Keyboarding Intermittently throughout the day. Seldom repetitive. Wrist Flexion/Extension While using keyboard, computer mouse. Handle/Grasp Simple grasping techniques requiring minimal force to handle office supplies, equipment. Forceful Grasp To lift heavier items. Fine Finger Manipulation While using keyboard and other office equipment. Must be able to write legibly. Hand Controls Controls on office equipment, vehicle. Foot Controls Operate vehicle. Repetitive Motion Body part: Hands While using keyboard, but typically this activity is intermittent. Vibratory Tasks - Low Vibratory Tasks - High Talking Must be able to communicate with residents, the general public and co-workers. Hearing Must be able to communicate with residents, the general public and co-workers. Tasting/Smelling Must be able to smell to verify cleanliness of "move outs", to assess safety and to evaluate complaints. Visual - Near Acuity Normal or corrected to normal vision is needed to perform computer work. Visual - Far Acuity Must be able to operate vehicle safely and assess property safety. Visual - Depth Perception Must be able to operate vehicle safely. Visual - Color Discrimination Visual - Accommodation Visual - Field Of Vision Based on F Page 4 of 6

7 Claimant: Claim No.: Job Title: Assistant Site Manager Body Part Injured: DOT Code: Environmental Conditions Frequency Activity Description Exposure to Weather May be exposed to inclement weather when walking between buildings on the property. Extreme Cold Extreme Hot Wet and / or Humidity May be exposed to inclement weather when walking between buildings on the property. Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals May be exposed to some infectious diseases and cleaning agents. Exposure to Radiation Other: Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 Analyst s Comments: 3 = Moderate, 4 = Loud, 5 = Very Loud Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

8 Claimant: Claim No.: Job Title: Assistant Site Manager Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

9 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Cashier DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Cashier Brief Job Description/Duties: Receives cash from customers in payment for goods or services and records amounts received using a cash register. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. 20 lbs. 10 lbs. 5 lbs. 1 lbs. Carry lbs. 20 lbs. 10 lbs. 5 lbs. lbs. Push / Pull lbs. lbs. lbs. lbs. 1 lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

10 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Cashier DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Cashier DOT Title: Cashier II SVP: 2 DOT #: Wage: Type of Industry: 249, Clerical and Kindred Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Cashier DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Receives cash from customers in payment for goods or services and records amounts received using a cash register. Essential Job Functions: Required to ring up cost of food on cash register, take payments, return change and balance register at end of the day. May be required to assist residents to table. May be required to carry money from facility to dining area and confirm amount. Training/Preparation Required: Employer will provide training. Must be able to perform basic math to balance register. Must be able to communicate in English. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Cash register Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week Based on F Page 2 of 6

11 Claimant: Body Part Injured: Claim No.: Job Title: Cashier DOT Code: % Time Sitting Sitting is performed up to four hours per day while performing cashier duties. Able to alternate sitting and standing intermittently. Standing Standing and walking are intermittent. Walking Standing and walking are intermittent. Job Demand Frequency & Weight Activity Description Lifting Carry (Dist.) 100 ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force Handle money and paperwork. Seldom lift up to 20 pounds such as the till and money at the end of the day. May carry food trays to tables. Occasionally may be required to carry money and change up to 100 feet at one time to and from the cashier area. May carry food trays to tables. May use minimal push/pull force to open and close the cash register drawer. Perform Work on Ladders Climb Stairs Twisting Stooping / Bending Bending at the waist may be performed. Squatting / Kneeling Crouching may be performed to pick up items dropped. Crawling Balancing Based on F Page 3 of 6

12 Claimant: Claim No.: Job Title: Cashier Body Part Injured: DOT Code: (Left/Right/Both) Reach Waist to Shoulder Reaching to exchange money or transport food trays. Work Above Shoulders Keyboarding Cash register key pad. Wrist Flexion/Extension Minimal flexion/extension to operate cash register. Handle/Grasp Constant handling and grasping money. Forceful Grasp When transporting food trays. Fine Finger Manipulation Frequent fingering when using the cash register to add up purchases and count coins. Hand Controls Hand controls are used on the cash register. Foot Controls Repetitive Motion Body part: Hands Operate cash register; intermittent with money handling. Vibratory Tasks - Low Vibratory Tasks - High Talking Talking/hearing is necessary for communicating with others and for taking instructions from others. Hearing Talking/hearing is necessary for communicating with others and for taking instructions from others. Tasting/Smelling Visual - Near Acuity Necessary for money handling. Visual - Far Acuity Visual - Depth Perception Visual - Color Discrimination Visual - Accommodation Visual - Field Of Vision Environmental Conditions Exposure to Weather Extreme Cold Extreme Hot Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Frequency Activity Description Based on F Page 4 of 6

13 Claimant: Claim No.: Job Title: Cashier Body Part Injured: DOT Code: Environmental Conditions Frequency Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud Analyst s Comments: Possible Employer Modifications: 3 Activity Description May be exposed to some infectious diseases and cleaning agents. Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 2/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

14 Claimant: Claim No.: Job Title: Cashier Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

15 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Community Site Manager DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Community Site Manager Brief Job Description/Duties: Manages Senior Community complex while living on-site. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. 20 lbs. 5 lbs. 2 lbs. lbs. Carry lbs. lbs. 5 lbs. 2 lbs. lbs. Push / Pull lbs. 10 lbs. 5 lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

16 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Community Site Manager DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Community Site Manager DOT Title: Manager, Apartment House SVP: 6 DOT #: Wage: Type of Industry: 731 Real Estate Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Community Site Manager DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Manages Senior Community complex while living on-site. Essential Job Functions: Shows prospective tenants apartments and explains occupancy terms. Informs prospective tenants of availability of nearby schools, shopping malls, recreational facilities, and public transportation. Rents or leases apartments, collects security deposit as required, and completes lease form outlining conditions and terms of occupancy when required. Collects rents due and issues receipts. Issues late notices and follows up on delinquencies. Investigates tenant complaints concerning malfunctions of utilities or furnished household appliances or goods, and inspects vacated apartments to determine need for repairs or maintenance. Directs and coordinates activities of maintenance staff engaged in repairing plumbing or electrical malfunctions, painting apartments or buildings, and performing landscaping or gardening work, or arranges for outside personnel to perform repairs. Directs and coordinates the driver and housekeeping. Resolves tenant complaints concerning other tenants or visitors. Training/Preparation Required: High School education and a minimum of four years experience as an Assistant Site Manager, Manager or related field; able to assist in performing the duties of the Site Manager in his/her absence; knowledge of or training in LIHT (Section 42) compliance; knowledge of computers and basic software application including Word, Excel, Internet, Outlook and where appropriate, property management software (e.g. AMSI); ability to work with other employees and address resident concerns in a professional manner; the ability to comprehend and perform all responsibilities of the position; neat, clean and professional appearance; must be able to communicate effectively in English - both verbal and written; valid driver's license with clean record and operational vehicle. Machine, Tools, Special Equipment, Personal Protective Equipment Used: PC Computer, printer, facsimile, copier, standard office supplies, and vehicle. Based on F Page 2 of 6

17 Claimant: Claim No.: Job Title: Community Site Manager Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting Sit in on-site office when providing assistance to residents - documenting concerns, answering questions, collecting rents, preparing marketing materials, etc. Sitting occurs in a swivel office chair. Standing Stand when assisting residents with questions and concerns. Standing occurs on carpet, tile, vinyl, asphalt and concrete surfaces. Stand and walk are intermittent throughout the shift with static standing limited to under 5 minutes in duration. Walking Walk when meeting prospective residents and showing the community. Walking occurs on carpet, tile, vinyl, asphalt and concrete surfaces. Stand and walk are intermittent throughout the shift with walking lasting up to 30 minutes when providing tours to prospective clients or hanging notices/flyers. Job Demand Frequency & Weight Activity Description Lifting Typical office supplies, decorations. Carry (Dist.) 10 ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force Carts are used to move larger and heavier items/boxes throughout the property as needed (holiday decorations, large supplies). Open/close drawers and doors. Seldom push cart with supplies. Based on F Page 3 of 6

18 Claimant: Claim No.: Job Title: Community Site Manager Body Part Injured: DOT Code: Perform Work on Ladders Climb Stairs Buildings have elevators available, but stairs may be used in emergencies. Twisting Must be able to twist at neck level to check blind spot while driving. Stooping / Bending To reach lower shelves and bottom drawer of filing cabinets - often performed from a seated position. Crouch/kneel can often be used in lieu of bend/stoop at the employee's discretion. Squatting / Kneeling See Stooping/Bending. Crawling Balancing (Left/Right/Both) Reach Waist to Shoulder Can be performed unilaterally or bilaterally. Work Above Shoulders Can be performed unilaterally or bilaterally. Keyboarding Intermittently throughout the day. Seldom repetitive. Wrist Flexion/Extension While using keyboard, computer mouse. Handle/Grasp Simple grasping techniques requiring minimal force to handle office supplies, equipment. Forceful Grasp To lift heavier items. Fine Finger Manipulation While using keyboard and other office equipment. Must be able to write legibly. Hand Controls Controls on office equipment, vehicle. Foot Controls Operate vehicle. Repetitive Motion Body part: Hands While using keyboard, but typically this activity is intermittent. Vibratory Tasks - Low Vibratory Tasks - High Talking Must be able to communicate with residents, the general public and co-workers. Hearing Must be able to communicate with residents, the general public and co-workers. Tasting/Smelling Must be able to smell to verify cleanliness of "move outs", to assess safety and to evaluate complaints. Visual - Near Acuity Normal or corrected to normal vision is needed to perform computer work. Visual - Far Acuity Must be able to operate vehicle safely and assess property safety. Visual - Depth Perception Must be able to operate vehicle safely. Based on F Page 4 of 6

19 Claimant: Claim No.: Job Title: Community Site Manager Body Part Injured: DOT Code: Visual - Color Discrimination Visual - Accommodation Visual - Field Of Vision Environmental Conditions Frequency Activity Description Exposure to Weather May be exposed to inclement weather when walking between buildings on the property. Extreme Cold Extreme Hot Wet and / or Humidity May be exposed to inclement weather when walking between buildings on the property. Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals May be exposed to some infectious diseases and cleaning agents. Exposure to Radiation Other: Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 Analyst s Comments: 3 = Moderate, 4 = Loud, 5 = Very Loud Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

20 Claimant: Claim No.: Job Title: Community Site Manager Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

21 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Cook Helper DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Cook Helper Brief Job Description/Duties: Assists Dietary cook in preparing foods. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift >50 lbs lbs lbs. 10 lbs. <10 lbs. Carry >50 lbs lbs lbs. 10 lbs. <10 lbs. Push / Pull lbs. lbs. <10 lbs. lbs. 2 lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

22 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Cook Helper DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Cook Helper DOT Title: Cook Helper SVP: 2 DOT #: Wage: Type of Industry: 453, Hotel Restaurant Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Cook Helper DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Assists Dietary cook in preparing foods. Essential Job Functions: May wash, peel, cut and seed vegetables and fruit. Cleans, cuts and grinds meats, poultry and seafood. May weigh and measure designated ingredients for recipe. Prepare salads, deserts and other side dishes. May prepare coffee and hot water. May wash all pots and knives used. May prepare trays for residents. Assist in cleaning of work area at the end of shift. Employee is required to handle food throughout the day. Employee must be able to be on feet all day. Also must be able to keep pace with a busy kitchen to ensure that food is prepared and ready for serving on time. Training/Preparation Required: Prior experience with food preparation. Food Handler's Permit. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Meat slicer, food processor, mixer, oven, steamer, spoons, knives, can openers, measuring spoons/cups, other kitchen equipment and supplies. Based on F Page 2 of 6

23 Claimant: Claim No.: Job Title: Cook Helper Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting Sitting is only allowed on breaks and at lunch. Standing Standing is performed for three to six hours out of an eight-hour day on tile floor, intermittent with walking for a total of eight hours per day. Some floor surfaces may be wet when dish washing or from food dropped on the floor. Walking Walking is performed for one to two hours at a time on tile floor. Some floor surfaces may be wet when dish washing or from food dropped on the floor. Job Demand Frequency & Weight Activity Description Lifting Lifting up to 10 pounds of meats when > <10 slicing is required. May also be required to lift various canned items weighing up to three pounds at a time. Lifting up to 25-pound boxes of vegetables may be required. Lifting up to 50-pound boxes of kale, lettuce or bags of potatoes may be lbs. required. Carry Frequently required to carry prepared (Dist.) 20 ft. > <10 foods weighing up to 10 pounds from preparation area to walk-in refrigerator. Carrying boxes of vegetables may be required. Up to 50 pound bags of lbs. potatoes may need to be carried. Pushing/ Occasionally required when using food Pulling <10 2 lbs. of cart to move items through kitchen. (Dist.) ft. force Based on F Page 3 of 6

24 Claimant: Claim No.: Job Title: Cook Helper Body Part Injured: DOT Code: Perform Work on Ladders Climb Stairs Twisting Occasional twisting at waist may occur while preparing food. Stooping / Bending Frequent bending may occur while cleaning work area or obtaining items from lower shelves. Squatting / Kneeling Occasional crouching may occur while cleaning or retrieving food items from lower shelves. Crawling Balancing (Left/Right/Both) Reach Waist to Shoulder Constant reaching when preparing food. Reaching below waist level is occasionally required when cleaning the kitchen area. Work Above Shoulders Reaching above shoulder height is occasionally required when reaching for food items on higher shelves. Keyboarding Wrist Flexion/Extension While preparing food. Handle/Grasp Constant handling and grasping is required while preparing food items. Forceful Grasp Required while using implements and while lifting heavy items. Fine Finger Manipulation While working with food. Hand Controls Operate kitchen equipment. Foot Controls Repetitive Motion Body part: Hands During food preparation. Vibratory Tasks - Low Vibratory Tasks - High Talking Necessary to communicate with others and for taking instructions from others. Hearing Necessary to communicate with others and for taking instructions from others. Tasting/Smelling The ability to taste and smell is a requirement of this position. Visual - Near Acuity Necessary to do the job effectively and correctly. Visual - Far Acuity Visual - Depth Perception Necessary to do the job effectively and correctly. Based on F Page 4 of 6

25 Claimant: Claim No.: Job Title: Cook Helper Body Part Injured: DOT Code: Visual - Color Discrimination Visual - Accommodation Visual - Field Of Vision Environmental Conditions Frequency Activity Description Exposure to Weather Extreme Cold Walk-in refrigerator. Extreme Hot Ovens. Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 Analyst s Comments: 3 = Moderate, 4 = Loud, 5 = Very Loud Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

26 Claimant: Claim No.: Job Title: Cook Helper Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

27 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Daycare Worker DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Daycare Worker Brief Job Description/Duties: Organize and lead activities of pre-kindergarten children. Provide a warm, nurturing, safe and loving environment where self-concepts are enhanced, independence encouraged, and individuality respected. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs lbs lbs lbs. <2 lbs. Carry lbs lbs lbs lbs. <2 lbs. Push / Pull lbs. lbs. lbs. 10 lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

28 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Daycare Worker DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Daycare Worker DOT Title: Nursery School Attendant SVP: 4 DOT #: Wage: Type of Industry: 138, Any Industry Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Daycare Worker DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Organize and lead activities of pre-kindergarten children. Provide a warm, nurturing, safe and loving environment where self-concepts are enhanced, independence encouraged, and individuality respected. Essential Job Functions: Interact with children. Plan weekly lessons. Maintain good communications with parents. Observe and record behavior, use appropriate discipline, and maintain records and files. Keep staff informed of program goals and developments and attend meetings and inservices. Prepare materials for the programs and report to the supervisor. Change and plan activities and room arrangements as needed. Perform other miscellaneous duties. Training/Preparation Required: Early childhood education is preferred. It is necessary to have CPR, First Aid, and HIV training. Must be 18 years old, have good communication skills, must not have been convicted of child abuse or any crime involving harm to another person. Evidence of emotional maturity and stability. Flexibility to accept changes in staffing patterns. Tolerance of different aspects of parenting and cultural background. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Toys, cleaning equipment, carts and a multitude of learning supplies. Based on F Page 2 of 6

29 Claimant: Claim No.: Job Title: Daycare Worker Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting Intermittent throughout the day while reading stories to children or assisting with program activities. Sitting may be performed at a standard desk, on the floor, or other seating arrangements. Sitting is usually not performed for more than two hours per day. Standing The majority of the day up to six to seven hours is performed while standing and walking around the Day Care facility at the nursing home site. Walking and standing would be performed on both carpeting and linoleum surfaces anywhere from 15 to 60 minutes at a time, depending on the specific activity. Walking The majority of the day, up to six to seven hours, job duties are performed while standing and walking around the Day Care facility at the nursing home site. Walking and standing would be performed on both carpeting and linoleum surfaces anywhere from 15 to 60 minutes at a time, depending on the specific activity. Job Demand Frequency & Weight Activity Description Lifting Lift books, toys and other items. Lift from <2 10 to 25 pounds while working with infants and using supplies and equipment. May lift up to 50 pounds while working with pre-school children or moving tables and chairs. Rarely, may be required to lift over 50 pounds if an older lbs. child is hurt. Carry There is frequent carrying of 10 to 25 (Dist.) 200 ft <2 pounds, and occasional to rare carrying of items up to 50 pounds and over 50 pounds. Maximum distance may be 100 lbs. to 200 feet. Pushing/ Pulling (Dist.) ft. N S O F 10 C lbs. of force There is frequent pushing and pulling performed to rearrange furniture, push a lunch cart, performing cleaning activities or other related tasks. Based on F Page 3 of 6

30 Claimant: Claim No.: Job Title: Daycare Worker Body Part Injured: DOT Code: Perform Work on Ladders Climb Stairs There is seldom climbing of stairs performed while performing activities in this position. Twisting There is frequent twisting at the waist and neck while taking part in developmental activities. Stooping / Bending There is frequent bending at the waist while working with the children as it is necessary to perform activities at their level. Squatting / Kneeling Frequent kneeling and squatting are also performed in this position while performing activities with the children. Crawling Crawling would be performed occasionally while taking part in developmental activities. Balancing (Left/Right/Both) Reach Waist to Shoulder Reaching is performed from ground level to overhead on a frequent basis. Bilateral reach is required. Work Above Shoulders Reaching is performed from ground level to overhead on a frequent basis. Bilateral reach is required. Keyboarding May be required to track information on the computer. Wrist Flexion/Extension When keyboarding. Handle/Grasp Frequent handle/grasp when engaging in activities. Forceful Grasp When lifting heavy items. Fine Finger Manipulation Is performed occasionally when doing activities with the children including drawing, cutting, etc. Hand Controls May use hand controls on equipment. Foot Controls No use of foot controls. Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking Must have excellent communication skills and be able to interact appropriately with children, parents and coworkers. Hearing Must have excellent communication skills and be able to interact appropriately with children, parents and coworkers. Tasting/Smelling Must be able to detect emergencies (i.e. fire) and determine when diapers need to be changed. Visual - Near Acuity Must be able to observe the work environment and the children in order to ensure their safety. Must be able to read books. Based on F Page 4 of 6

31 Claimant: Claim No.: Job Title: Daycare Worker Body Part Injured: DOT Code: Visual - Far Acuity Must be able to observe the work environment and the children in order to ensure their safety. Visual - Depth Perception Must be able to observe the work environment and the children in order to ensure their safety. Visual - Color When working on developmental activities with children. Discrimination Visual - Accommodation To perform various job duties. Visual - Field Of Vision Must be able to observe the work environment and the children in order to ensure their safety. Environmental Conditions Exposure to Weather Extreme Cold Extreme Hot Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: May change soiled diapers. Noise Intensity Frequency 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud 3 Activity Description Some cleaning supplies. Analyst s Comments: Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

32 Claimant: Claim No.: Job Title: Daycare Worker Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

33 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Dietary Cook DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Dietary Cook Brief Job Description/Duties: Prepares and cooks meals for residents and employees. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift >50 lbs lbs lbs. 10 lbs. <10 lbs. Carry lbs lbs lbs. 10 lbs. <10 lbs. Push / Pull lbs. lbs. 2 lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

34 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Dietary Cook DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Dietary Cook DOT Title: Cook SVP: 6 DOT #: Wage: Type of Industry: 138, Any Industry Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Dietary Cook DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Prepares and cooks meals for residents and employees. Essential Job Functions: Cooks food in quantities according to the menu and number of persons to be served. Plans menu, taking advantage of foods in season and local availability. May serve meals. May order supplies and keep records and accounts. May direct activities of one or more workers who assist in preparing and serving meals. Prepare various foods depending on menu created by dietitians, for each meal of the day. Operate kitchen equipment in preparation for meals. Required to clean work surfaces following shift: sweep floors, wipe down counter space, cover and store unused foods. Must be able to create meals that are appropriate for the elderly and in large quantities. Employee is required to use institutional size cookware. Must be able to work at a constant pace to ensure the food is ready for each meal of the day. Employee is required to handle food throughout the day. Types of foods: meats, raw vegetables, fresh fruit, canned foods. Training/Preparation Required: A minimum of 1-2 years training/experience. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Spoons, knives, can openers, measuring spoons/cups, meat slicer, stove, oven, food processor, blender, various pots and pans, and other kitchen equipment and supplies. Based on F Page 2 of 6

35 Claimant: Claim No.: Job Title: Dietary Cook Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting Sitting is only performed during breaks. Standing Static standing and walking are alternated throughout the day. Some floor surfaces may be wet from dish washing or from food dropped on the floor. Walking Walking short distances is intermittent with standing throughout the day. Some floor surfaces may be wet from dish washing or from food dropped on the floor. Job Demand Frequency & Weight Activity Description Lifting Carry (Dist.) 20 ft. Pushing/ Pulling (Dist.) ft. > < <10 2 lbs. lbs. lbs. of force Frequent lifting of up to 10 pounds is required when preparing various food items and using kitchen equipment, i.e. cutting five pound hams on industrial size slicer. Occasional lifting up to 25 pounds when lifting items filled with soup or stew. Lifting up to 50 pounds is rarely required when lifting a 50-pound bag of potatoes - this can be deferred to other workers if the employee is not able to lift this amount. Carrying up to 10 pounds is frequently required when carrying various food items within the kitchen area, usually a distance of five to 20 feet. Carrying up to 25 pounds may be rarely required to carry filled pots from one burner to another. Carrying up to 50 pounds is required on a rare basis when carrying a 50-pound bag of potatoes. Occasionally may be required when pushing and pulling baking sheets to and from the oven with little resistance. Based on F Page 3 of 6

36 Claimant: Claim No.: Job Title: Dietary Cook Body Part Injured: DOT Code: Perform Work on Ladders Climb Stairs Twisting Occasional twisting at the waist while cooking. Stooping / Bending Frequent bending at the waist is performed in the course of performing the various job tasks. Squatting / Kneeling Occasional crouching while retrieving items from lower shelves. Crawling Crawling is not a requirement of this position. Balancing (Left/Right/Both) Reach Waist to Shoulder Reaching from 1/2 to full arm extension is required. Occasional reaching below waist level. Work Above Shoulders Reaching above shoulder level is occasionally required when reaching for food items in refrigerator or spices on shelves. Keyboarding Wrist Flexion/Extension While cooking food. Handle/Grasp Constant handling and grasping is performed in this position while performing job tasks. Forceful Grasp Constant while holding implements or lifting heavy items. Fine Finger Manipulation While cooking food and operating controls. Hand Controls Hand controls such as push buttons, turn knobs, and dials are intermittently used throughout the work shift. Foot Controls Repetitive Motion Body part: Hands While cooking. Vibratory Tasks - Low Vibratory Tasks - High Talking Necessary for communicating with others and for taking instructions from others. Hearing Necessary for communicating with others and for taking instructions from others. Tasting/Smelling Necessary for testing quality of food products. Visual - Near Acuity Necessary for testing quality of food products. Visual - Far Acuity Visual - Depth Perception Necessary to do the job effectively and correctly. Visual - Color Discrimination Visual - Accommodation Visual - Field Of Vision Must be able to see full range of visual field. Based on F Page 4 of 6

37 Claimant: Claim No.: Job Title: Dietary Cook Body Part Injured: DOT Code: Environmental Conditions Frequency Activity Description Exposure to Weather Extreme Cold Walk-in refrigerator. Extreme Hot Ovens. Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 Analyst s Comments: 3 = Moderate, 4 = Loud, 5 = Very Loud Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 2/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

38 Claimant: Claim No.: Job Title Dietary Cook Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

39 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Dishwasher DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Dishwasher Brief Job Description/Duties: Assist in maintaining kitchen work areas and keeping equipment, utensils and food plates clean and orderly. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. lbs lbs. <25 lbs. <10 lbs. Carry lbs. lbs lbs. <25 lbs. <10 lbs. Push / Pull lbs. lbs. lbs. <10 lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

40 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Dishwasher DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Dishwasher DOT Title: Kitchen Helper SVP: 2 DOT #: Wage: Type of Industry: 453, Hotel & Restaurant Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Dishwasher DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Assist in maintaining kitchen work areas and keeping equipment, utensils and food plates clean and orderly. Essential Job Functions: Ability to operate industrial dishwater and to perform repetitive work according to set procedures. Sweep and mop floors of kitchen and may be required to sweep and mop dining area. May be required to wash food preparation work tables, walls, refrigerators and refrigerated walk-ins. Required to remove garbage from kitchen area and hose out garbage containers. Training/Preparation Required: This job can be learned through on the job training. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Dishwasher, rolling carts, dish tubs, mop and broom. Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week Based on F Page 2 of 6

41 Claimant: Claim No.: Job Title: Dishwasher Body Part Injured: DOT Code: % Time Sitting Sitting is only performed during breaks. Standing Static standing is performed while operating dishwasher, intermittent with walking on tiled floor surface. Some floor surfaces may be wet when dish washing or from food dropped on the floor. Walking Walking frequently, intermittent with standing while performing job tasks. Some floor surfaces may be wet when dish washing or from food dropped on the floor. Job Demand Frequency & Weight Activity Description Lifting Lift trays of dishes to be loaded and <25 <10 unloaded into the dishwasher. Occasional lifting of up to 20-pound lbs. buckets of ice. Carry The items lifted may be carried a (Dist.) 20 ft <25 <10 lbs. distance of approximately 5-20 feet. Pushing/ Push carts of dishes and when pushing Pulling <10 lbs. of the trays into and out of the dishwasher. (Dist.) ft. force Perform Work on Ladders Climb Stairs Twisting At waist and neck level while washing dishes. Stooping / Bending While performing job duties. Squatting / Kneeling Crouching may be performed at the discretion of the worker in place of bending as appropriate. Crawling Balancing (Left/Right/Both) Reach Waist to Shoulder To operate the dishwasher and perform regular job tasks. Work Above Shoulders To access high shelves. Keyboarding Wrist Flexion/Extension To wash dishes. Handle/Grasp Repetitive arm and hand motions are used to load and unload the dishwasher and clean food off plates. Twist at wrist level. Forceful Grasp To lift heavy items. Based on F Page 3 of 6

42 Claimant: Claim No.: Job Title: Dishwasher Body Part Injured: DOT Code: Fine Finger Manipulation Intermittently operate dials and controls on the equipment while utilizing manual and finger dexterity. Hand Controls Intermittently operate dials and controls on equipment while utilizing manual and finger dexterity. Foot Controls Repetitive Motion Body part: Arm/Hands Repetitive arm and hand motions are used to load and unload the dishwasher and clean food off plates. Vibratory Tasks - Low Vibratory Tasks - High Talking Must be able to communicate with co-workers and supervisors. Hearing Must be able to communicate with co-workers and supervisors. Tasting/Smelling Visual - Near Acuity Must be able to determine if dishes are clean. Visual - Far Acuity Visual - Depth Perception Visual - Color Discrimination Visual - Accommodation Visual - Field Of Vision Environmental Conditions Frequency Activity Description Exposure to Weather Extreme Cold Walk in refrigerator. Extreme Hot Ovens. Wet and / or Humidity Dishwasher. Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Some cleaning supplies. Exposure to Radiation Other: Based on F Page 4 of 6

43 Claimant: Claim No.: Job Title: Dishwasher Body Part Injured: DOT Code: Environmental Conditions Frequency Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud Analyst s Comments: Possible Employer Modifications: 4 Activity Description Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

44 Claimant: Claim No.: Job Title: Dishwasher Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

45 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Driver DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Driver Brief Job Description/Duties: Drives shuttle van to transport passengers to and from stores, planned lunches, post office, library and other planned outings. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. 45 lbs. 20 lbs. 2 lbs. lbs. Carry lbs. 45 lbs. 20 lbs. 2 lbs. lbs. Push / Pull lbs. 25 lbs. lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

46 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Driver DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Driver DOT Title: Driver SVP: 3 DOT #: Wage: Type of Industry: 593 Motor Vehicle Transportation Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Driver DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Drives shuttle van to transport passengers to and from stores, planned lunches, post office, library and other planned outings. Essential Job Functions: Provide transportation based on monthly events calendar from manager. Assist residents in and out of van. Assist with securing/storage of wheelchairs/walkers and purchased items. Maintain cleanliness of vans, keep vans full of petrol and notify management of vehicle mechanical operation concerns. Training/Preparation Required: Must be at least 18 years old; experience preferred. Must have driver's license and be insurable. Must have clean record. Must be able to communicate in English. Machine, Tools, Special Equipment, Personal Protective Equipment Used: 12 passenger bus and 8 passenger van, cleaning supplies, writing implement and clip board. Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week Based on F Page 2 of 6

47 Claimant: Claim No.: Job Title: Driver Body Part Injured: DOT Code: % Time Sitting While driving, up to 30 minutes at a time. Standing Alternated with frequent walking and sitting. Walking Walk between parking lot and residence; most often on concrete or asphalt. Alternated with sitting and standing. Job Demand Frequency & Weight Activity Description Lifting Carry (Dist.) 10 ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force Lift items such as pen/pencil, cleaning supplies, groceries, shopping bags, and walkers (can weigh up to 20 pounds). SELDOM lift/carry up to 45 pounds less than 10 feet when storing wheelchairs. Carry items such as pen/pencil, cleaning supplies, groceries, shopping bags, and walkers (can weigh up to 20 pounds). SELDOM lift/carry up to 45 pounds less than 10 feet when storing wheelchairs. Push/pull vehicle doors and straps to secure wheelchairs in place. SELDOM use 25 pounds force to push/pull wheelchairs into place in the van or to assist residents in/out of the van. Perform Work on Ladders Climb Stairs Climb three steps in and out of vans. Twisting At neck level while checking blind spot. May twist at waist to secure wheelchairs. Stooping / Bending Assist residents to enter/exit van and to store items in cargo space. Squatting / Kneeling May crouch when accessing folding mechanism for van chair 3 times per week. May choose to crouch in lieu of stooping. Crawling May be required when accessing folding mechanism for van chair roughly 3 times per week. Balancing (Left/Right/Both) Reach Waist to Shoulder While driving, storing purchases and assisting residents. May also occasionally reach below waist level. Work Above Shoulders To store items. Keyboarding Wrist Flexion/Extension Based on F Page 3 of 6

48 Claimant: Claim No.: Job Title: Driver Body Part Injured: DOT Code: Handle/Grasp Steering wheel, pen/pencil, wheelchairs, walkers, shopping bags and additional supplies. Forceful Grasp Steering wheel, pen/pencil, wheelchairs, walkers, shopping bags and additional supplies. Fine Finger Manipulation Perform various job duties. Hand Controls Vehicle controls. Foot Controls Vehicle controls. Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking Must be able to communicate with residents and coworkers. Hearing Must be able to communicate with residents and coworkers. Tasting/Smelling Visual - Near Acuity Must be able to pass driving exam and read/write in English. Visual - Far Acuity Must be able to pass driving exam. Visual - Depth Perception Must be able to pass driving exam. Visual - Color Discrimination Visual - Accommodation Visual - Field Of Vision Must be able to navigate traffic and pass driving exam. Environmental Conditions Frequency Activity Description Exposure to Weather When getting in/out of vehicle. Extreme Cold Extreme Hot Wet and / or Humidity During inclement weather. Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals May be exposed to some infectious diseases and cleaning agents. Exposure to Radiation Other: Noise Intensity 1 = Very Quiet, 2 = Quiet, 4 3 = Moderate, 4 = Loud, 5 = Very Loud Based on F Page 4 of 6

49 Claimant: Claim No.: Job Title: Driver Body Part Injured: DOT Code: Analyst s Comments: Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

50 Claimant: Claim No.: Job Title: Driver Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

51 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Feeder/Bedmaker DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Feeder/Bedmaker Brief Job Description/Duties: Provide additional assistance to housekeeping and nursing staff. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs lbs lbs. 10 lbs. lbs. Carry lbs. lbs. lbs. 10 lbs. lbs. Push / Pull lbs. lbs. lbs. 10 lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

52 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Feeder/Bedmaker DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Feeder/Bedmaker DOT Title: Nurse Assistant SVP: 3 DOT #: Wage: Type of Industry: 573, Medical Services Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Feeder/Bedmaker DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Provide additional assistance to housekeeping and nursing staff. Essential Job Functions: Assist in changing residents' bed linens and feeding residents their meals in the dining area. Fill the utility cart with clean linens to take to the individual residents rooms, chang linens on residents beds (remove soiled linens and replace with clean ones). Assist in passing out fresh water to residents and picking up the used water pitchers. May be required to turn mattresses, checking for any tears in the mattress. Assist residents to the dining room. Pass food trays to individual residents in accordance with the diet card on the tray. Document the intake of the residents on a specified card. Assist in the feeding of residents that require this help. Stock the utility rooms with clean linens from the laundry area. May be required to clean residents' combs and brushes. Training/Preparation Required: Prior training or experience is preferred. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Linen cart and supply cart. Based on F Page 2 of 6

53 Claimant: Claim No.: Job Title: Feeder/Bedmaker Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting Only during breaks and lunch. Standing Alternated with walking on a carpeting, linoleum and tile floors. Walking Alternated with standing on carpeting, linoleum and tile floors. Job Demand Frequency & Weight Activity Description Lifting Carry (Dist.) 10 ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force Lift up to 10 pounds (i.e. stacks of linens). Lift pounds to flip mattresses on a weekly basis. Lift over 50 pounds, up to 100 pounds, to assist in transfer of a resident from a bed to a wheelchair. Carry up to 10 pounds of bed linens from a cart into rooms, up to 10 feet. Carrying over 10 pounds is not required for this position. Pushing is required when wheeling the laundry cart from the utility area to the rooms. The utility cart rolls easily across carpeting or tile floors. Perform Work on Ladders Climb Stairs Twisting Twisting at the waist while changing bed linens. Stooping / Bending Bending may occur while assisting resident from bed to wheelchair or while assisting in feeding of residents. Squatting / Kneeling At the discretion of the worker, while changing bed linen. Crawling Balancing Based on F Page 3 of 6

54 Claimant: Claim No.: Job Title: Feeder/Bedmaker Body Part Injured: DOT Code: (Left/Right/Both) Reach Waist to Shoulder To make beds or feed residents. Bilateral reach is required. Work Above Shoulders When restocking utility room with clean linens from laundry area. Keyboarding Wrist Flexion/Extension Handle/Grasp Bed linens, eating utensils, etc. Forceful Grasp Bed linens, eating utensils, etc. Fine Finger Manipulation Intermittently performed while assisting with residents with feeding. Hand Controls To perform job duties. Foot Controls Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking Necessary for communicating with others and for taking instruction from others. Hearing Necessary for communicating with others and for taking instruction from others. Tasting/Smelling In order to detect soiled sheets. Visual - Near Acuity To perform job duties. Visual - Far Acuity To perform job duties. Visual - Depth Perception Visual - Color Discrimination To perform job duties. Visual - Accommodation Visual - Field Of Vision Environmental Conditions Exposure to Weather Extreme Cold Extreme Hot Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Frequency Activity Description Based on F Page 4 of 6

55 Claimant: Claim No.: Job Title: Feeder/Bedmaker Body Part Injured: DOT Code: Environmental Conditions Frequency Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Soiled sheets. Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud Analyst s Comments: Possible Employer Modifications: 2 Activity Description May be exposed to some infectious diseases and cleaning agents. Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

56 Claimant: Claim No.: Job Title: Feeder/Bedmaker Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

57 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Home Care Specialist DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Home Care Specialist Brief Job Description/Duties: Cares for elderly, convalescent or disabled person in his/her home. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. 25 lbs. 20 lbs. 10 lbs. lbs. Carry lbs. lbs. lbs. 10 lbs. lbs. Push / Pull lbs. 25 lbs. 10 lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 7 Index: VOC

58 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Home Care Specialist DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Home Care Specialist DOT Title: Home Attendant SVP: 3 DOT #: Wage: Type of Industry: 674 Personal Service Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Home Care Specialist DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Cares for elderly, convalescent or disabled person in his/her home. Essential Job Functions: Change bed linens. Wash and iron patient's laundry. Perform light cleaning of patient's residence, which includes light vacuuming, washing dishes, dusting, sweeping and wiping counters. Purchase, prepare, and serve food for patient. Assist patient in dressing and grooming including nail and hair care. Assist with toilet use, changing bed pans, emptying catheter bags,assist with changing colostomy bag, and assist with undergarments. Assist with ambulation and transfers, and changes position of patients that are bed riden. Ensure that patient takes prescribed medications. Accompany patient outside home, serving as guide, companion and aide. Perform a variety of miscellaneous duties as requested, such as obtaining household supplies and running errands. May maintain records of services performed and of apparent condition of patient. May visit several households to provide daily health care to patients. Must be able to perform CPR. Training/Preparation Required: Prior experience is preferred. Any required training is provided to the worker after hire, such as Orientation, "Fundamentals of Care Giving" and CPR courses. A clean criminal background (via State Patrol and DSHS) is required as is a Washington State Driver's License (WSDL). Based on F Page 2 of 7

59 Claimant: Claim No.: Job Title: Home Care Specialist Body Part Injured: DOT Code: Machine, Tools, Special Equipment, Personal Protective Equipment Used: Walker, wheelchair, cane, crutches, gait belt, personal vehicle, exercise equipment, ace bandages, grocery cart, vacuum, mop, buckets, broom, snow shovel, washing machine, dryer, iron, needle, thread, sewing machine, stove, oven, microwave, pots and pans, can opener, blender, mixers, knives, kitchen utensils, hair brush, comb, nail files, razor, hospital beds, charts, portable commode, catheter, colostomy bag, urinal, bed pan. Safety equipment includes gloves. Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting Alternated with standing and walking. Standing Alternated with sitting and walking. Walking Alternated with sitting and standing on asphalt, concrete, carpet, tile, etc. Job Demand Frequency & Weight Activity Description Lifting Lift items like linens, grooming implements, cooking utensils, and bags of groceries weighing negligible ounces up to 10 lbs. Employee lifts up to 20 lbs. OCCASIONALLY. On a SELDOM basis the employee will lift items that weigh up lbs. to 25 lbs. Carry Items will be carried for short distances (Dist.) 50 ft. 10 within stores, household, and medical facility could be 5-10 feet, up to 50 feet. When shopping, an employee can utilize lbs. a cart. Pushing/ Pulling (Dist.) ft. N S 25 O 10 F C lbs. of force Utilizes up to 10 lbs. of push/pull force to vacuum, push cart, and perform various other duties throughout the workday. Employee will seldom utilize up to 25 lbs. of push/pull force to assist client with ambulation, transfers and turning in bed: please note that employee is not to lift patient and should utilize assistive devices as needed. Push wheelchairs on a seldom basis. In regards to pushing wheelchairs the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require Based on F Page 3 of 7

60 Claimant: Claim No.: Job Title: Home Care Specialist Body Part Injured: DOT Code: Job Demand Frequency & Weight Activity Description 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. Each employee performs CPR on a SELDOM basis. CPR is needed 1-2 times per week throughout the facility and multiple employees perform this function. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives typically 1-4 minutes. Perform Work on Ladders Climb Stairs May climb stairs at the patient's home; however, if the patient does not have any stairs at the residence, then this would not be a requirement. The employee is NOT to climb on chairs or ladders, but may utilize a sturdy 2- step stool that has handrails. Twisting Twists at the waist, neck and wrist levels when performing regular duties. Employee can reduce twisting at the waist level by re-positioning the entire body. Stooping / Bending Bends at the waist when performing regular duties, such as making beds, helping with bathing and/or dressing, etc. Employee may substitute crouching or kneeling for bending at the waist at his/her own discretion. Please note that the employee must have the ability to perform CPR. Squatting / Kneeling On a rare basis, may need to kneel or crouch to retrieve items at floor level or to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee s discretion. Crawling Balancing (Left/Right/Both) Reach Waist to Shoulder Reach out in front of the body to assist patient with ADLs, feeding, cleaning, and other similar duties. Work Above Shoulders Overhead reaching to retrieve supplies on high shelves and reaching below the waist level may occur OCCASIONALLY. Keyboarding Based on F Page 4 of 7

61 Claimant: Claim No.: Job Title: Home Care Specialist Body Part Injured: DOT Code: Wrist Flexion/Extension Handle/Grasp A variety of items including cooking utensils, food items, grooming implements, etc. Handling/grasping is light in nature. Forceful Grasp To perform some job duties. Fine Finger Manipulation When preparing food, clipping patient's nails, and when writing. Hand Controls Operates/uses controls on oven, washer/dryer, vacuum, vehicle, etc. Foot Controls To operate vehicle. Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking Employee must be able to communicate with patients. Hearing Employee must be able to communicate with patients. Tasting/Smelling Must be able to assess cleanliness and danger. Visual - Near Acuity To perform job duties. Visual - Far Acuity While driving. Visual - Depth Perception While driving. Visual - Color Discrimination To perform job duties. Visual - Accommodation To perform job duties. Visual - Field Of Vision To perform job duties. Based on F Page 5 of 7

62 Claimant: Claim No.: Job Title: Home Care Specialist Body Part Injured: DOT Code: Environmental Conditions Frequency Activity Description Exposure to Weather While walking outside. Extreme Cold Extreme Hot Wet and / or Humidity During inclement weather. Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals May be exposed to some infectious diseases and cleaning agents. Exposure to Radiation Other: Soiled sheets/clothes. Noise Intensity 1 = Very Quiet, 2 = Quiet, 2 Analyst s Comments: 3 = Moderate, 4 = Loud, 5 = Very Loud Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 6 of 7

63 Claimant: Claim No.: Job Title: Home Care Specialist Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 7 of 7

64 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Homemaker DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Homemaker Brief Job Description/Duties: Responsible for the delivery of care to the residents living in the independent living dwellings. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs lbs. lbs. 10 lbs. lbs. Carry lbs. 25 lbs. lbs. 10 lbs. lbs. Push / Pull lbs. lbs. 5 lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

65 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Homemaker DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Homemaker DOT Title: Personal Attendant SVP: 3 DOT #: Wage: Type of Industry: 319, Domestic Services Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Homemaker DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Responsible for the delivery of care to the residents living in the independent living dwellings. Essential Job Functions: Perform some housecleaning; i.e., dusting, mopping, vacuuming, laundry, etc. May be required to grocery shop for residents. May be required to prepare meals for residents. May be required to assist in bathing and dressing of residents. Responsible for notifying the nursing staff of the condition of the residents if the condition has changed and the need for further medical care is warranted. Training/Preparation Required: Employee must be able to communicate effectively, verbally and in writing. Must be able to work well with others and especially the elderly. Must be able to problem-solve and work well alone. Valid Washington State Drivers License, personal vehicle, and auto insurance with clean dirving record. Prior experience is preferred. Any required training is provided to the worker after hire. A clean criminal background (via State Patrol and DSHS). Machine, Tools, Special Equipment, Personal Protective Equipment Used: May be required to operate an automobile and cleaning equipment as well as kitchen appliances. Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week Based on F Page 2 of 6

66 Claimant: Claim No.: Job Title: Homemaker Body Part Injured: DOT Code: % Time Sitting Alternated with standing and walking. Standing Alternated with walking on varying floor surfaces including carpet, linoleum, tile and concrete for up to three hours a day. Walking Alternated with standing on varying floor surfaces including carpet, linoleum, tile and concrete for up to three hours a day. Job Demand Frequency & Weight Activity Description Lifting Carry (Dist.) ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force Lifting up to 10 pounds is required when performing various housecleaning duties; i.e., vacuuming, emptying garbage containers, etc. Lifting of up to 25 pounds occurs when lifting groceries if resident requires this service. Lifting up to and over 50 pounds is rarely required to assist resident in bathing which may result in bearing weight of resident with some assistance. Carrying up to 10 pounds is required when performing various housecleaning duties; i.e., vacuuming, emptying garbage containers, etc. Carrying up to 25 pounds may be required when grocery shopping for resident. Carrying over 25 pounds is not required. Occasional pushing/pulling while vacuuming residence. Perform Work on Ladders Climb Stairs May climb stairs, up to two to three flights. Elevators are typically available. Twisting Twisting at the waist may occur while performing cleaning duties or doing laundry. Twist at neck while driving. Stooping / Bending Bending at the waist occurs while dusting and cleaning. Squatting / Kneeling Crawling Balancing (Left/Right/Both) Based on F Page 3 of 6

67 Claimant: Claim No.: Job Title: Homemaker Body Part Injured: DOT Code: Reach Waist to Shoulder To perform job duties. Work Above Shoulders May occur when housecleaning or placing food items on shelves for resident after shopping. Keyboarding Wrist Flexion/Extension Handle/Grasp Handling of objects of varying sizes and weights such as canned foods, cleaning supplies, etc. Forceful Grasp Handling of objects of varying sizes and weights such as canned foods, cleaning supplies, etc. Fine Finger Manipulation To perform job duties. Hand Controls Use of foot controls and hand controls are required when driving a vehicle to perform shopping for residents. Will operate kitchen appliances. Foot Controls Use of foot controls and hand controls are required when driving a vehicle to perform shopping for residents. Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking Necessary for communicating and taking instructions from others. Hearing Necessary for communicating and taking instructions from others. Tasting/Smelling May be used when cooking for the resident or smelling chemicals/smoke or cleanliness. Visual - Near Acuity To perform job duties. Visual - Far Acuity Must be able to safely drive. Visual - Depth Perception Must be able to safely drive. Visual - Color Discrimination To perform job duties. Visual - Accommodation Visual - Field Of Vision Must be able to safely drive. Environmental Conditions Frequency Activity Description Exposure to Weather While walking to/from vehicle. Extreme Cold Extreme Hot Wet and / or Humidity During inclement weather. Proximity to Moving Mechanical Parts Based on F Page 4 of 6

68 Claimant: Claim No.: Job Title: Homemaker Body Part Injured: DOT Code: Environmental Conditions Frequency Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Soiled sheets/clothing Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud Analyst s Comments: Possible Employer Modifications: 2 Activity Description May be exposed to some infectious diseases and cleaning agents. Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

69 Claimant: Claim No.: Job Title: Homemaker Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

70 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Housekeeper Assisted Living DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Housekeeper Assisted Living Brief Job Description/Duties: Provide cleaning service to maintain clean rooms and common areas for assisted living residents. Worker will clean five residential units per day. Linens are changed by the Resident Service Associates (RSA) not Housekeeping. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. 20 lbs. lbs. 5 lbs. lbs. Carry lbs. 20 lbs. lbs. 5 lbs. lbs. Push / Pull lbs. lbs. 15 lbs. 5 lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

71 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Housekeeper Assisted Living DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Housekeeper Assisted Living DOT Title: Cleaner, Housekeeping SVP: 2 DOT #: Wage: Type of Industry: 138 Any Industry Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Housekeeper Assisted Living DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Provide cleaning service to maintain clean rooms and common areas for assisted living residents. Worker will clean five residential units per day. Linens are changed by the Resident Service Associates (RSA) not Housekeeping. Essential Job Functions: Pick up trash from kitchen, dining room, public restroom and laundry. Mop public restroom, laundry and kitchen. Clean public restroom and check toilet paper, soap, toilet seat cover and paper towel. Use broom and dust pan to clean carpet in dining room. Vacuum rooms. Assist with extra projects as assigned. Training/Preparation Required: The ability to follow verbal instruction and perform routine work. Ability to read English for cleaning/chemical labels (writing not necessary). Must pass background check. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Vacuum, housekeeping cart, cleaning rags, mop bucket, cleaning supplies, gloves and respiratory mask for viral sanitizing. Based on F Page 2 of 6

72 Claimant: Claim No.: Job Title: Housekeeper Assisted Living Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting SELDOM sit. Standing While performing daily job tasks up to two hours at a time, up to eight hours total per day, interspersed with walking between rooms. Standing occurs on carpeted, wood and vinyl floors. Stand and walk combined are CONSTANT. Walking Walking between rooms performed intermittently with static standing throughout the work shift. Maximum distance walked at one time is 50 feet between rooms and residential units. Walking occurs on carpeted, wood, concrete and vinyl floors. Walk and stand combined are CONSTANT. Job Demand Frequency & Weight Activity Description Lifting Lift up to 5 pounds of cleaning supplies, 20 5 dirty clothes, and garbage. 4-6 times per day lift up to 20 pounds for mop bucket of lbs. water and vacuum. Carry From 1 to 20 pounds when moving full (Dist.) 20 ft mop bucket. Carrying occurs between supply closets and the cart or to/from a lbs. room to the cart. Pushing/ Push/pull vacuum, mop and broom. Pulling 15 5 lbs. of Push/pull housekeeping cart requiring 15 (Dist.) ft. force pounds force. Perform Work on Ladders Climb Stairs Twisting Twist at the waist while wiping down beds, cleaning tight bathroom spaces and walls, vacuuming, and mopping. Based on F Page 3 of 6

73 Claimant: Claim No.: Job Title: Housekeeper Assisted Living Body Part Injured: DOT Code: Stooping / Bending Bending at the waist while performing cleaning activities, special projects (i.e. wiping down patio furniture, removing chair marks on walls). Crouch/kneel/bend/stoop may be used interchangeably at employee s discretion. Squatting / Kneeling Crouch/kneel/bend/stoop may be used interchangeably at employee s discretion. Crawling Balancing (Left/Right/Both) Reach Waist to Shoulder Majority of daily cleaning requirements mopping, vacuuming, cleaning mirrors and windows, sinks, tables and emptying garbage. Seldom reach below waist to clean areas close to floor or to pick up items. Bilateral reach is required. Work Above Shoulders Chest level to overhead: SELDOM for cleaning walls, kitchen cupboards, windows and dusting. Keyboarding Wrist Flexion/Extension While performing some cleaning duties. Handle/Grasp Light force when handling cleaning materials. Forceful Grasp Forceful grasping is needed when vacuuming, performing cleaning duties and moving housekeeping cart. Fine Finger Manipulation To perform job duties. Hand Controls Operate finger and foot controls to turn the vacuum on/off. Foot Controls Operate finger and foot controls to turn the vacuum on/off. Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking Must be able to communicate with supervisors, coworkers and residents. Hearing Must be able to communicate with supervisors, coworkers and residents. Tasting/Smelling Must be able to discriminate smells for sanitary conditions. Visual - Near Acuity To verify cleanliness and navigate facility. Visual - Far Acuity Navigate facility. Visual - Depth Perception Based on F Page 4 of 6

74 Claimant: Claim No.: Job Title: Housekeeper Assisted Living Body Part Injured: DOT Code: Visual - Color Discrimination Visual - Accommodation Visual - Field Of Vision Environmental Conditions Exposure to Weather Extreme Cold Extreme Hot Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Soiled items. Noise Intensity Frequency 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud 3 Activity Description May be exposed to some infectious diseases and cleaning agents. Analyst s Comments: Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

75 Claimant: Claim No.: Job Title: Housekeeper Assisted Living Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

76 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Housekeeper Nursing Home DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Housekeeper Nursing Home Brief Job Description/Duties: Provide cleaning service to maintain clean rooms and common areas in nursing home. Worker will clean up to 30 rooms per day. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. 20 lbs. lbs. 5 lbs. lbs. Carry lbs. 20 lbs. lbs. 5 lbs. lbs. Push / Pull lbs. 35 lbs. 15 lbs. 5 lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 7 Index: VOC

77 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Housekeeper Nursing Home DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Housekeeper Nursing Home DOT Title: Cleaner, Housekeeping SVP: 2 DOT #: Wage: Type of Industry: 138 Any Industry Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Housekeeper Nursing Home DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Provide cleaning service to maintain clean rooms and common areas in nursing home. Worker will clean up to 30 rooms per day. Essential Job Functions: Pick up trash, remove garbage from room. Remove bed linens and place in laundry chute; replace with new clean linens. Mop and clean bathroom mirrors, sink, toilet, shower and floors. Vacuum resident room and entry way (janitor vacuums halls). Clean inside windows as needed. Provide wall washing and deep cleaning for viral infection decontamination. Wipe down hydraulic bed frames as assigned. Assist with extra projects as assigned. Training/Preparation Required: The ability to follow verbal instruction and perform routine work. Ability to read English for cleaning/chemical labels (writing not necessary). Must pass background check. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Vacuum, housekeeping cart, linens, mop bucket, cleaning supplies, gloves, respiratory mask for viral sanitizing. Based on F Page 2 of 7

78 Claimant: Claim No.: Job Title: Housekeeper Nursing Home Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting SELDOM sit. Standing While performing daily job tasks up to two hours at a time, up to eight hours total per day, interspersed with walking between rooms. Standing occurs on carpeted, wood and vinyl floors. Stand and walk combined are CONSTANT. Walking Walking between rooms performed intermittently with static standing throughout the work shift. Maximum distance walked at one time is 50 feet between rooms and residential units. Walking occurs on carpeted, wood, concrete and vinyl floors. Walk and stand combined are CONSTANT. Job Demand Frequency & Weight Activity Description Lifting Lift up to 5 pounds of cleaning supplies, 20 5 dirty clothes, and garbage. 4-6 times per day lift up to 20 pounds for mop bucket of lbs. water and vacuum. Carry From 1 to 20 pounds when moving full (Dist.) 20 ft mop bucket. Carrying occurs between supply closets and the cart or to/from a lbs. room to the cart. Pushing/ Pulling (Dist.) ft. N S 35 O 15 F 5 C lbs. of force Push/pull vacuum, mop and broom. Push/pull housekeeping cart requiring 15 pounds force. SELDOM move bed frames with caster wheels requiring 35 pounds force. Perform Work on Ladders Climb Stairs Twisting Twist at the waist while wiping down beds, cleaning tight bathroom spaces and walls, vacuuming, and mopping. Based on F Page 3 of 7

79 Claimant: Claim No.: Job Title: Housekeeper Nursing Home Body Part Injured: DOT Code: Stooping / Bending Bending at the waist while performing cleaning activities, special projects (i.e. wiping down patio furniture, removing chair marks on walls). Crouch/kneel/bend/stoop may be used interchangeably at employee s discretion. Squatting / Kneeling Crouch/kneel/bend/stoop may be used interchangeably at employee s discretion. Crawling Balancing (Left/Right/Both) Reach Waist to Shoulder Majority of daily cleaning requirements mopping, vacuuming, cleaning mirrors and windows, sinks, tables and emptying garbage. Seldom reach below waist to clean areas close to floor or to pick up items. Bilateral reach is required. Work Above Shoulders Chest level to overhead: SELDOM for cleaning walls and windows and dusting. Keyboarding Wrist Flexion/Extension While performing some cleaning duties. Handle/Grasp Light force when handling cleaning materials. Forceful Grasp Forceful grasping is needed when vacuuming, performing cleaning duties and moving housekeeping cart. Fine Finger Manipulation To perform job duties. Hand Controls Operate finger and foot controls to turn the vacuum on/off. Foot Controls Operate finger and foot controls to turn the vacuum on/off. Repetitive Motion Body part: Vibratory Tasks - Low Exposure to upper extremity vibration when vacuuming. Vibratory Tasks - High Talking Must be able to communicate with supervisors, coworkers and residents. Hearing Must be able to communicate with supervisors, coworkers and residents. Tasting/Smelling Must be able to discriminate smells for sanitary conditions. Visual - Near Acuity To verify cleanliness and navigate facility. Visual - Far Acuity Navigate facility. Visual - Depth Perception Visual - Color Discrimination Based on F Page 4 of 7

80 Claimant: Claim No.: Job Title: Housekeeper Nursing Home Body Part Injured: DOT Code: Visual - Accommodation Visual - Field Of Vision Based on F Page 5 of 7

81 Claimant: Claim No.: Job Title: Housekeeper Nursing Home Body Part Injured: DOT Code: Environmental Conditions Exposure to Weather Extreme Cold Extreme Hot Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Soiled items. Noise Intensity Frequency 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud 3 Activity Description May be exposed to some infectious diseases and cleaning agents. Analyst s Comments: Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 6 of 7

82 Claimant: Claim No.: Job Title: Housekeeper Nursing Home Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 7 of 7

83 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Housekeeper - Retirement DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Housekeeper - Retirement Community Brief Job Description/Duties: Assist in maintaining and cleaning common areas in a senior retirement apartment community. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. 20 lbs. lbs. 5 lbs. lbs. Carry lbs. 20 lbs. lbs. 5 lbs. lbs. Push / Pull lbs. lbs. 15 lbs. 5 lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

84 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Housekeeper - Retirement Community DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Housekeeper - Retirement Community DOT Title: Cleaner, Housekeeping SVP: 2 DOT #: Wage: Type of Industry: 138 Any Industry Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Housekeeper - Retirement DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Assist in maintaining and cleaning common areas in a senior retirement apartment community. Essential Job Functions: Disinfect and clean community bathrooms in each building (sink, toilet, floors, mirrors). Vacuum, sweep and/or mop all halls, community room, sun rooms, kitchens and lobby. Dust and clean library, community areas, window sills, windows and stair wells. Training/Preparation Required: The ability to follow verbal instruction and perform routine work. Ability to read English for cleaning/chemical labels (writing not necessary). Must pass background check. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Vacuum, housekeeping cart, mop and bucket, cleaning supplies and Motorola walkie/talkies. Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week Based on F Page 2 of 6

85 Claimant: Claim No.: Job Title: Housekeeper - Retirement Body Part Injured: DOT Code: % Time Sitting Seldom sit. Standing Standing occurs intermittently with walking so together these two demands occur on a CONSTANT basis. Standing tends to be dynamic, occurring in conjunction with movement in such a way as to involve frequent changes of position. Standing occurs over level surfaces within the establishment. Stand/walk on carpeted/linoleum/concrete floors. Walking Walking occurs intermittently with standing so together these two demands occur on a CONSTANT basis. Walking occurs over level surfaces within the establishment. Stand/walk on carpeted/linoleum/concrete floors. Job Demand Frequency & Weight Activity Description Lifting Cleaning supplies, garbage, mop bucket The heaviest item lifted is the vacuum cleaner with attachments (approximately 20 pounds) and it is lifted 8 off the floor lbs. to the cleaning cart. Carry From 1 to 20 pounds when moving full (Dist.) 20 ft mop bucket. Carrying occurs for distances of up to 20 feet between supply closets and the cart or to/from a room to lbs. the cart. Pushing/ Pulling (Dist.) ft. N S O 15 F 5 C lbs. of force FREQUENTLY with variable force when cleaning, using the vacuum, moving patio furniture or moving the rolling cart. Push/pull force required for the cart is approximately 15 pounds and the maximum required of all job tasks. Perform Work on Ladders Climb Stairs Twisting Twist at waist when vacuuming, moping and cleaning. Stooping / Bending Bending at the waist while performing cleaning activities, special projects (i.e. wiping down patio furniture, removing chair marks on walls). Crouch/kneel/bend/stoop may be used interchangeably at employee s discretion. Squatting / Kneeling Crouch/kneel/bend/stoop may be used interchangeably at employee s discretion. Crawling Balancing Based on F Page 3 of 6

86 Claimant: Claim No.: Job Title: Housekeeper - Retirement Body Part Injured: DOT Code: (Left/Right/Both) Reach Waist to Shoulder Majority of daily cleaning requirements mopping, vacuuming, cleaning mirrors and windows, sinks, tables and emptying garbage. Seldom reach below waist to clean areas close to floor or to pick up items. Bilateral reach is required. Work Above Shoulders Chest level to overhead: SELDOM for cleaning walls and windows and dusting. Keyboarding Wrist Flexion/Extension While performing some cleaning duties. Handle/Grasp Light force when handling cleaning materials. Forceful Grasp Forceful grasping is needed when vacuuming, performing cleaning duties and moving housekeeping cart. Fine Finger Manipulation To perform job duties. Hand Controls Operate finger and foot controls to turn the vacuum on/off. Foot Controls Operate finger and foot controls to turn the vacuum on/off. Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking Must be able to communicate with supervisors, coworkers and residents. Hearing Must be able to communicate with supervisors, coworkers and residents. Tasting/Smelling Must be able to discriminate smells for sanitary conditions. Visual - Near Acuity To verify cleanliness and navigate facility. Visual - Far Acuity Navigate facility. Visual - Depth Perception Visual - Color Discrimination Visual - Accommodation Visual - Field Of Vision Based on F Page 4 of 6

87 Claimant: Claim No.: Job Title: Housekeeper - Retirement Body Part Injured: DOT Code: Environmental Conditions Exposure to Weather Extreme Cold Extreme Hot Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Soiled items. Noise Intensity Frequency 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud 3 Activity Description May be exposed to some infectious diseases and cleaning agents. Analyst s Comments: Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

88 Claimant: Claim No.: Job Title: Housekeeper - Retirement Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

89 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Kitchen Aid DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Kitchen Aid Brief Job Description/Duties: Provides assistance in the kitchen area prior to, during and after meals are served to the residents. This position is primarily used to assist the kitchen and nursing staff in providing assistance wherever needed. Must be able to tolerate the fast pace of a busy kitchen. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs lbs lbs. 10 lbs. lbs. Carry lbs. lbs lbs. 10 lbs. lbs. Push / Pull lbs. lbs. 15 lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

90 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Kitchen Aid DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Kitchen Aid DOT Title: Kitchen Helper SVP: 2 DOT #: Wage: Type of Industry: 453, Hotel and Restaurant Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Kitchen Aid DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Provides assistance in the kitchen area prior to, during and after meals are served to the residents. This position is primarily used to assist the kitchen and nursing staff in providing assistance wherever needed. Must be able to tolerate the fast pace of a busy kitchen. Essential Job Functions: May be required to provide assistance to the nursing staff by passing water to residents within the facility. May assist dishwasher following meal in scraping plates. May assist prep cook in preparing deserts or snacks for residents. May set up meal trays for residents according to special diets and personal requests. May be required to note the amount of food consumed by the residents during the meal. May be required to carry trays to residents who are ill. May be required to clean tables in the dining area after each meal. Training/Preparation Required: Job duties can be learned through short term on the job training. Ability to interact with residents. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Water pitcher, cooking/preparation utensils, trays, glasses, plates, etc. Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week Based on F Page 2 of 6

91 Claimant: Claim No.: Job Title: Kitchen Aid Body Part Injured: DOT Code: % Time Sitting Standing Frequent standing and walking up to two hours at a time, up to eight hours total on surfaces including carpeting, linoleum and tile. Some floor surfaces may be wet when dish washing or from food dropped on the floor. Walking Frequent walking and standing up to two hours at a time, up to eight total on surfaces including carpeting, linoleum and tile. Some floor surfaces may be wet when dish washing or from food dropped on the floor. Job Demand Frequency & Weight Activity Description Lifting Frequent lifting up to 10 pounds when assisting dishwasher and emptying trays. Pull trays from tray rack which may contain plates, utensils and glassware. Occasional lifting 10 to 20 pounds (a stack of clean trays, etc). Seldom lift 5 gallon water jugs weighing up to 50 lbs. pounds. Carry Carry food trays to ill residents in their (Dist.) 20 ft room. Full trays may weigh 10 pounds. Occasionally carry a stack of clean trays to a holding area weighing from 10 to 20 pounds a distance of approximately 10 to 20 feet at one time. Not required to carry lbs. anything over 20 pounds. Pushing/ Pulling (Dist.) ft. N S O 15 F C lbs. of force Occasional pushing during the course of a day when passing water pitchers and when pushing a cart holding the water pitchers. Cart rolls easily across tile surface. Perform Work on Ladders Climb Stairs Twisting Occasional twisting at waist when assisting dishwasher or passing water pitchers to residents. Stooping / Bending To perform various job duties. Squatting / Kneeling Crawling Balancing Based on F Page 3 of 6

92 Claimant: Claim No.: Job Title: Kitchen Aid Body Part Injured: DOT Code: (Left/Right/Both) Reach Waist to Shoulder When passing water pitchers and when cleaning tables in dining area after each meal. Occasional reaching below waist when assisting the dishwasher. Occasional repetitive arm and hand motion when scraping plates and loading trays for the dishwasher. Work Above Shoulders To perform various job duties. Keyboarding Wrist Flexion/Extension Handle/Grasp Constant handling of various items such as food, plastic water pitchers, plastic food trays, utensils and various sizes of glassware. Occasional repetitive arm and hand motion when scraping plates and loading trays for the dishwasher. Forceful Grasp To lift heavy items, scrape plates, etc. Fine Finger Manipulation To perform various job duties. Hand Controls Use of hand controls may be required to operate kitchen equipment. Foot Controls Repetitive Motion Body part: Arm/Hand When scraping dishes. Vibratory Tasks - Low Vibratory Tasks - High Talking Necessary for communicating with others and for taking instructions from others. Hearing Necessary for communicating with others and for taking instructions from others. Tasting/Smelling Visual - Near Acuity Necessary for doing the job effectively and correctly. Visual - Far Acuity Necessary for doing the job effectively and correctly. Visual - Depth Perception Visual - Color Discrimination Visual - Accommodation Visual - Field Of Vision Environmental Conditions Frequency Activity Description Exposure to Weather Extreme Cold Walk-in refrigerator. Extreme Hot Ovens, dishwasher. Wet and / or Humidity Kitchen floors, dishwasher. Based on F Page 4 of 6

93 Claimant: Claim No.: Job Title: Kitchen Aid Body Part Injured: DOT Code: Environmental Conditions Frequency Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud Analyst s Comments: Possible Employer Modifications: 4 Activity Description May be exposed to some infectious diseases and cleaning agents. Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

94 Claimant: Claim No.: Job Title: Kitchen Aid Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

95 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Laundry Worker, Nursing Home DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Laundry Worker Nursing Home Brief Job Description/Duties: Worker maintains supply of clean linens, towels and clothes for use by residents and/or staff. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. lbs lbs. 3-5 lbs. 2 lbs. Carry lbs. lbs. 15 lbs. lbs. lbs. Push / Pull lbs. lbs. lbs. lbs. 10 lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 7 Index: VOC

96 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Laundry Worker Nursing Home DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Laundry Worker Nursing Home DOT Title: Laundry Worker II SVP: 2 DOT #: Wage: Type of Industry: 138 Any Industry Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Laundry Worker, Nursing Home DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Worker maintains supply of clean linens, towels and clothes for use by residents and/or staff. Essential Job Functions: Retrieve laundry from laundry chutes using carts approximately 30"x67"x42" (1 cubic yard capacity). Sort laundry into groups: sheets and gowns, blankets, bath blankets and soiled items. Each resident's personal laundry arrives separately, is weighed and charged by the pound. Load articles into commercial front load washers (opening approximately 32" off floor) and add specified amount of detergent. Average of loads of laundry each day. Pull wet articles from washer to cart measuring with false bottom at 24" off floor. Place wet articles into commercial front load dryers (opening center approximately 33" off floor). Remove articles from dryer into cart and fold on counter at 36" height. Place clean folded articles on portable wire storage racks with shelves at 12", 30", 48" and 60" off floor or in appropriate storage bin. May return storage racks to utility closets on resident floors for housekeeping and staff use. May hang clothes on racks according to name and numbers. May deliver all personal laundry to designated areas. May ensure that all clothes are mended and ready to wear. Specific jobs as assigned by supervisor. Training/Preparation Required: One year of experience in a commercial establishment. Ability to meet the physical demands of the position. Basic English communication skills. No GED required. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Industrial front load washers and dryers, scale, wire racks, carts, various rolling baskets and bins and hangers. Based on F Page 2 of 7

97 Claimant: Claim No.: Job Title: Laundry Worker, Nursing Home Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting Standing Dynamic standing while sorting and folding articles. Static standing may occur up to 5 minutes uninterrupted while folding at the counter. Stand and walk are alternated regularly throughout the shift. Standing occurs on vinyl, non-skid painted concrete and industrial carpeted floors. Walking Walking up to 10 minutes when moving empty/full laundry racks to specified location throughout facility and when retrieving dirty laundry from laundry chutes. This is necessary approximately every 30 minutes and shared with other laundry staff. Walking occurs on vinyl, non-skid painted concrete and industrial carpeted floors. Job Demand Frequency & Weight Activity Description Lifting Floor to Waist Level: CONSTANT up to pounds for individual articles. FREQUENT 3-5 pounds for wet linens and blankets. Waist to Shoulder Level: CONSTANT up to 2 pounds for individual articles. FREQUENT 3-5 pounds for stacks of clean linens, wet linens and blankets. OCCASIONAL 6-15 pounds for stacks of larger linens. Shoulder Level to Overhead: OCCASIONAL up to 2 pounds for hanging resident laundry on lbs. racks. Carry OCCASIONAL carry of ounces to 15 (Dist.) 5 ft. 15 pounds up to 5 feet to place stacks of clean linens on storage racks. Various carts are available to move items around the facility and minimize necessary lbs. carrying. Pushing/ Pulling (Dist.) ft. 10 lbs. of force FREQUENTLY items are pulled from the washer and dryer requiring 3-4 pulls per load. Items are rolled directly into a cart and never carried.constant push/pull Based on F Page 3 of 7

98 Claimant: Claim No.: Job Title: Laundry Worker, Nursing Home Body Part Injured: DOT Code: Job Demand Frequency & Weight Activity Description laundry carts loaded with dirty linens from chutes, push/pull dirty resident laundry from scale and push/pull dirty linens from sorting bins. Push/pull will also be used to load and unload washer and dryer and to move hanging clothes racks and to move clean laundry to folding table. Push/pull force is typically less than 10 pounds. SELDOM push/pull of rolling storage shelving requires a push/pull force up to 30 pounds. Push/pull occurs on vinyl, non-skid painted concrete and industrial carpeted floors. Perform Work on Ladders Climb Stairs Elevators are available. Twisting Twisting at waist when loading and unloading washer and dryer. Twisting may be minimized by re-positioning of the feet. Stooping / Bending Bending up to 45 degree angle when loading and unloading washers, dryers and baskets. Opening to dryers and washers is at approximate waist height, Squatting / Kneeling Required once a day to clean the lent traps in the dryers. Crawling Balancing (Left/Right/Both) Reach Waist to Shoulder Waist to shoulder level: FREQUENT when retrieving items from dryer (drum is 50 deep) and washer and when folding articles of clothing/linens. FREQUENT reach to remove dirty clothes from laundry chute and to place clean items on shelves. Floor to waist level: OCCASIONAL when retrieving items from sorting carts and residents personal items from scale. As needed for dropped articles. Work Above Shoulders Shoulder level to overhead: SELDOM when hanging clothes on hanging racks and placing linens on upper shelves. Keyboarding Wrist Flexion/Extension Handle/Grasp CONSTANT handling and grasping of linens and clothes, both wet and dry. Based on F Page 4 of 7

99 Claimant: Claim No.: Job Title: Laundry Worker, Nursing Home Body Part Injured: DOT Code: Forceful Grasp Grasping of carts and storage rack as needed requiring a stronger grasp. Fine Finger Manipulation FREQUENT fine finger manipulation while folding linens and personal items belonging to residents. Hand Controls FREQUENTLY operate the hand controls on the washers/dryers (push button, knobs, dial turn, etc.) Foot Controls Repetitive Motion Body part: Arms/Hands Repetitively reach and grasp to perform job duties. Vibratory Tasks - Low Vibratory Tasks - High Talking Talking/hearing is needed to communicate with others and when taking instructions. Basic English is okay. Hearing Talking/hearing is needed to communicate with others and when taking instructions. Basic English is okay. Tasting/Smelling Smell is needed to detect odors and soiled articles. Taste is not a requirement of this position. Visual - Near Acuity Must be able to detect cleanliness and to read labels. Visual - Far Acuity To navigate facility. Visual - Depth Perception Visual - Color Discrimination Visual - Accommodation Visual - Field Of Vision Environmental Conditions Frequency Activity Description Exposure to Weather Extreme Cold Extreme Hot In laundry area. Wet and / or Humidity In laundry area. Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals May be exposed to some infectious diseases and cleaning agents. Exposure to Radiation Other: Soiled items. Based on F Page 5 of 7

100 Claimant: Claim No.: Job Title: Laundry Worker, Nursing Home Body Part Injured: DOT Code: Environmental Conditions Frequency Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud Analyst s Comments: Possible Employer Modifications: 3 Activity Description Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 6 of 7

101 Claimant: Claim No.: Job Title: Laundry Worker, Nursing Home Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 7 of 7

102 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: LPN - Assisted Living DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Licensed Practical Nurse (LPN) -Wellness Nurse Assisted Living Brief Job Description/Duties: Assists RN Wellness Nurse in providing education counseling and appropriate nursing services that assist village residents in living their lives. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs lbs lbs. 10 lbs. lbs. Carry lbs. lbs. 10 lbs. 5 lbs. lbs. Push / Pull lbs lbs. 10 lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 7 Index: VOC

103 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Licensed Practical Nurse (LPN) -Wellness Nurse Assisted Living DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Licensed Practical Nurse (LPN) - Wellness Nurse Assisted Living DOT Title: Nurse, Licensed Practical SVP: 6 DOT #: Wage: Type of Industry: 573 Medical Services Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: LPN - Assisted Living DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Assists RN Wellness Nurse in providing education counseling and appropriate nursing services that assist village residents in living their lives. Essential Job Functions: Checks RSA (Resident Service Associate) Logs daily and coordinates 24 hour report. Provides or delegates, as appropriate, direct nursing services, treatment and assistance to residents. Works closely with the RN Wellness Nurse to provide staff development (RSA initial and ongoing training) and supervision. Under the direction of the RN Wellness Nurse, completes the resident assessments prior to resident move in, 30 days after resident move in, semiannually and when there is a change in condition. Coordinates and schedules individual Resident Service Plan with each resident, his/her family and staff (30 day and semiannual). Notifies family of recommended service package changes resulting from change in condition. Visits each resident quarterly and updates assessment if appropriate. Under the direction of the RN Wellness Nurse, executes the Quality Assurance Program. May provide shopping for residents. May assist with payroll and monthly resident billing. Performs other duties as assigned by management to meet changing job-related requirements. Training/Preparation Required: Current Washington State LPN License with current necessary training under Washington State WAC regulations. High School diploma and three years of college or comparable education. One year experience. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Blood pressure cuff, thermometer, stethoscope, gloves, telephone, transfer belt, computer and medical equipment/supplies. Based on F Page 2 of 7

104 Claimant: Claim No.: Job Title: LPN - Assisted Living Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting While charting activities and medical information by computer and/or hand and communicating with families. Standing Intermittent with walking while making rounds and checking on residents. Floor surfaces are generally carpet, linoleum, tile or concrete. Walking Intermittent with standing while making rounds and checking on residents. Floor surfaces are generally carpet, linoleum, tile or concrete. Job Demand Frequency & Weight Activity Description Lifting Carry (Dist.) ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force FREQUENT lift of 0-10 pounds for resident files and individual medical supplies. Lifting up to 25 pounds required when stocking medical supplies. Lifting up to 50 pounds is rarely (1-2 time per month) required to assist or transfer residents. The correct use of a transfer belt is required to avoid injury to the resident or nurse. Lifting is performed from floor to shoulder level. Lifting over shoulder level is SELDOM. FREQUENT up to 5 ponds. OCCASIONAL up to 10 pounds when carrying resident treatment bag or other items. Carts are used for moving items weighing more than 10 pounds, such as medical equipment and supplies. OCCASIONAL push/pull cart with medical equipment and supplies requiring up to 10 pounds of force. SELDOM push/pull cart loaded with heavier supplies requiring push/pull force up to 25 pounds. Typically cart rolls easily over concrete walkways, carpeting and tile. Push wheelchairs on a SELDOM Based on F Page 3 of 7

105 Claimant: Claim No.: Job Title: LPN - Assisted Living Body Part Injured: DOT Code: Job Demand Frequency & Weight Activity Description basis. In regards to pushing wheelchairs the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. CPR is performed on a SELDOM basis - on average 2-4 times per year. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives typically 1-4 minutes. Perform Work on Ladders Climb Stairs Twisting OCCASIONAL twisting at the waist may occur when providing medical treatments, assisting in transfer or when applying/changing daily bandages and leg wraps. Stooping / Bending Bending required when providing treatment to residents, administering medications, taking vital signs and assisting seated residents. Must be able to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee s discretion. Squatting / Kneeling On a rare basis may need to kneel or crouch to retrieve items at floor level. Must be able to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee s discretion. Crawling Balancing Must be able to balance when assisting residents with movement, employee does not work at heights. (Left/Right/Both) Reach Waist to Shoulder Reaching FREQUENTLY at all levels from standing and seated positions up to full arm extension when administering to residents who are bedridden and seated, reaching for supplies and using phone, charting information. Work Above Shoulders When reaching for medical records, dishes and supplies located on shelves. Keyboarding To access and document information. Based on F Page 4 of 7

106 Claimant: Claim No.: Job Title: LPN - Assisted Living Body Part Injured: DOT Code: Wrist Flexion/Extension While keyboarding. Handle/Grasp FREQUENT grasping when handling pens/pencils for documenting information into medical charts, when handling paperwork and while using various medical supplies/equipment (stethoscope, thermometer, medications, syringes, etc.). Forceful Grasp Forceful grasp used when pushing resident in wheelchair and performing some nursing duties. Fine Finger Manipulation OCCASIONAL fine finger manipulation while using the computer and telephone and when performing first aid and administering shots. Hand Controls OCCASIONAL intermittent use of various hand controls with knobs to turn, buttons to push and switches to flip as needed for blood pressure cuff and various other medical equipment. Foot Controls The use of foot controls is SELDOM. Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking Necessary for communicating with others, safety awareness and for taking instructions from physicians and supervisor. Must be able to communicate in English. Hearing Necessary for communicating with others, safety awareness and for taking instructions from physicians and supervisor. Must be able to communicate in English. Tasting/Smelling Smell is required and necessary to detect dangerous odors when providing wound treatment and performing health assessment Visual - Near Acuity CONSTANT for doing job effectively and correctly. Visual - Far Acuity To navigate facility. Visual - Depth Perception To perform various job duties Visual - Color Discrimination To perform various job duties Visual - Accommodation To perform various job duties Visual - Field Of Vision CONSTANT for doing job effectively and correctly. Environmental Conditions Exposure to Weather Extreme Cold Frequency Activity Description Based on F Page 5 of 7

107 Claimant: Claim No.: Job Title: LPN - Assisted Living Body Part Injured: DOT Code: Environmental Conditions Extreme Hot Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity Analyst s Comments: Frequency 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud Possible Employer Modifications: 2 Activity Description Will be exposed to household chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry. Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 6 of 7

108 Claimant: Claim No.: Job Title: LPN - Assisted Living Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 7 of 7

109 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: LPN - Nursing Home DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Licensed Practical Nurse (LPN), Primary Care - Nursing Home Brief Job Description/Duties: The LPN will direct, administer and record the care given to residents in an assigned section of the nursing facility. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. 250 lbs lbs. 10 lbs. lbs. Carry lbs. lbs. 10 lbs. 5 lbs. lbs. Push / Pull lbs. 35 lbs. 25 lbs. 10 lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 8 Index: VOC

110 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Licensed Practical Nurse (LPN), Primary Care - Nursing Home DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Licensed Practical Nurse (LPN), Primary Care - Nursing Home DOT Title: Nurse, Licensed Practical SVP: 6 DOT #: Wage: Type of Industry: 573 Medical Services Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: LPN - Nursing Home DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: The LPN will direct, administer and record the care given to residents in an assigned section of the nursing facility. Essential Job Functions: Documentating and directing the other nursing staff in performing care for the resident. Communicate with family members regarding the progress of the resident. Assist visiting physicians in rounds. Draw blood and obtain fluids to submit for lab work. May be required to complete intravenous infusion/injection. Record and issue appropriate medications. May be required to work with Alzheimer's residents who are not cooperative. Record and monitor all progress of residents and communicate with physicians. May be required to assist in passing out trays to residents in dining area and assist in feeding. Monitor work of other nursing staff in unit to ensure thoroughness. Required to use telephones to communicate with physicians, arrange for transportation for doctor appointments and contact families. Make rounds to ensure cleanliness and proper care to residents. Coordinate care of residents. Manages all NAC staff in section. Assists staff members according to needs. Follow set protocol in emergency situation. Training/Preparation Required: Current Washington State LPN License with current necessary training under Washington State WAC regulations. High School diploma and three years of college or comparable education. One year experience. Based on F Page 2 of 8

111 Claimant: Claim No.: Job Title: LPN - Nursing Home Body Part Injured: DOT Code: Machine, Tools, Special Equipment, Personal Protective Equipment Used: Computer, telephone, gowns, goggles, gloves, masks, Accucheck (Blood Sugar), scale, blood pressure cuff, bladder scanner, pulse oximeter, thermometer, oxygen concentration, IV pumps, portable oxygen and various first aid supplies and equipment. Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting OCCASIONAL while charting activities and medical information by computer and/or hand, when phoning doctors, taking orders and communicating with families. Standing OCCASIONAL standing intermittent with walking is performed for up to two hours at a time while making rounds and checking on residents. Employer states static stand up to 2 minutes at one time when administering treatments. Twice per week static standing is required up to 45 minutes for longer treatments. Floor surfaces are generally carpet, linoleum, tile or concrete. Walking FREQUENT walking intermittent with standing. Floor surfaces are generally carpet, linoleum, tile or concrete. Job Demand Frequency & Weight Activity Description Lifting FREQUENT lift up to 10 pounds for resident files and supplies. Lifting pounds OCCASIONALLY required for medical supplies/equipment. SELDOM lifting up to 50 pounds to assist and transfer residents with transfer belt. The correct use of a transfer belt is required to avoid injury to the resident or nurse. Vera Lift and Vander Lifts are used to minimize weight. Lifting primarily performed from floor to shoulder level. Lifting over lbs. shoulder level is SELDOM. Carry FREQUENT up to 5 pounds. (Dist.) ft lbs. OCCASIONAL 5-10 pounds to move Based on F Page 3 of 8

112 Claimant: Claim No.: Job Title: LPN - Nursing Home Body Part Injured: DOT Code: Job Demand Frequency & Weight Activity Description items from one location in the facility to another. Carts are available for heavier supplies and/or equipment. Pushing/ Pulling (Dist.) ft lbs. of force FREQUENT push/pull cart with medical equipment and supplies requiring up to 10 pounds of force. SELDOM push/pull cart loaded with heavier supplies requiring push/pull force up to 25 pounds. Typically cart rolls easily over concrete walkways, carpeting and tile. Push wheelchairs on an OCCASIONAL basis. In regards to pushing wheelchairs the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. Each employee performs CPR on a SELDOM basis. CPR is needed 1-2 times per week throughout the facility and multiple employees perform this function. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives typically 1-4 minutes. Perform Work on Ladders Climb Stairs Twisting OCCASIONAL twisting may occur while providing patient care. Stooping / Bending OCCASSIONAL bending may occur when providing treatment to residents, administering medications, taking vital signs and assisting seated residents, etc. Must be able to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee s discretion. Squatting / Kneeling On a rare basis, may need to kneel or crouch to retrieve items at floor level or to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee s discretion. Crawling Based on F Page 4 of 8

113 Claimant: Claim No.: Job Title: LPN - Nursing Home Body Part Injured: DOT Code: Balancing Must be able to balance when assisting residents with movement, employee does not work at heights. (Left/Right/Both) Reach Waist to Shoulder Reaching FREQUENTLY at all levels from standing and seated positions up to full arm extension when administering to residents who are bedridden and seated, reaching for supplies and using phone, charting information. Work Above Shoulders Above shoulder level OCCASIONAL when attending patients with tubes and IVs and to obtain supplies on shelves. Keyboarding To access and document information. Wrist Flexion/Extension While keyboarding. Handle/Grasp FREQUENT handling paperwork, pens/pencils, telephone and various medical supplies/equipment (i.e. stethoscope, thermometer, medications, syringes, etc). Forceful Grasp Forceful grasp used when pushing resident in wheelchair and performing some nursing duties. Fine Finger Manipulation OCCASIONAL fine finger manipulation while using the computer keyboard, writing, and when performing first aid, administering shots and medications. Hand Controls FREQUENT use of various hand controls with knobs to turn, buttons to push and switches to flip as needed for blood pressure cuff and various other medical equipment. Foot Controls The use of foot controls may be required for hydraulic beds, wheelchair brakes, etc. Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking Necessary for safety awareness and for communicating and taking instructions from physicians, labs, pharmacists, families and supervisor. Ability to read, write, and speak English. Hearing Necessary for safety awareness and for communicating and taking instructions from physicians, labs, pharmacists, families and supervisor. Ability to read, write, and speak English. Tasting/Smelling Smell is required and necessary to detect dangerous odors, provide wound treatment and to perform health assessment/diagnosis. Based on F Page 5 of 8

114 Claimant: Claim No.: Job Title: LPN - Nursing Home Body Part Injured: DOT Code: Visual - Near Acuity Must be able to read labels, doctor s instructions, medication orders, charts and medical history. Visual - Far Acuity To navigate facility. Visual - Depth Perception To perform various job duties. Visual - Color Discrimination To perform various job duties. Visual - Accommodation To perform various job duties. Visual - Field Of Vision CONSTANT for doing job effectively and correctly. Environmental Conditions Exposure to Weather Extreme Cold Extreme Hot Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity Frequency 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud 2 Activity Description Will be exposed to household and hospital chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry. May use mask, goggles and gowns. Possible exposure to needle pricks. Analyst s Comments: Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Based on F Page 6 of 8

115 Claimant: Claim No.: Job Title: LPN - Nursing Home Body Part Injured: DOT Code: Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 7 of 8

116 Claimant: Claim No.: Job Title: LPN - Nursing Home Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 8 of 8

117 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Maintenance DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Maintenance Brief Job Description/Duties: Repair and maintain physical structure of senior housing community consisting of 300 plus residential units, common areas and facilities. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. lbs lbs. 10 lbs. lbs. Carry lbs lbs. 25 lbs. lbs. 5 lbs. Push / Pull lbs. lbs. 25 lbs. lbs. 5 lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 8 Index: VOC

118 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Maintenance DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Maintenance DOT Title: Maintenance Repairer, Building SVP: 7 DOT #: Wage: Type of Industry: 138 Any Industry Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Maintenance DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Repair and maintain physical structure of senior housing community consisting of 300 plus residential units, common areas and facilities. Essential Job Functions: General maintenance may require plumbing repairs such as unclogging hair traps, unpluging toilets and repair washer/dryers, refrigerators and stoves. May be required to maintain and replace electrical outlets, and light bulbs. May be required to remove furniture and clothing from rooms no longer occupied. May be required to paint interior or exterior of facility. May be required to install and check batteries of smoke alarms. May be required to assist Fire Marshall with inspections. May be required to maintain the grounds of the facility. May assist in holiday decoration installation and removal. Training/Preparation Required: Two plus years experience in maintenance and repair; well rounded knowledge of electrical, plumbing and appliances; acceptable background check. High school diploma/ged required. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Various power tools and hand tools and electrical and plumbing supplies. Hand truck, dolly and carts. May be required to operate a vehicle. Based on F Page 2 of 8

119 Claimant: Claim No.: Job Title: Maintenance Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting Rarely to perform repairs or while driving. Standing Occasional static standing is performed up to 15 minutes at a time on varying surfaces such as carpet, linoleum, tile, concrete, gravel, dirt, and grass. Standing is intermittent with walking and combined occur on a frequent basis. Walking Walking is frequent and alternated with static standing. Walking on various surfaces such as carpet, linoleum, tile, concrete, dirt and grass to move around the facility, work area and maintenance room. Job Demand Frequency & Weight Activity Description Lifting FREQUENT lift up to 10 pounds for tools and supplies. OCCASIONAL lift 10 to 25 pounds (cans of paint and various other equipment and supplies). OCCASIONAL lifting up to 50 pounds when lifting various supplies or equipment. Assistance is available in moving furniture that weighs over 50 pounds, so that the worker will not be lifting over 50 pounds as part of the shared weight. Hand truck, dolly and carts are available lbs. to move heavier items. Carry Wear a tool belt containing tools weighing (Dist.) 100 ft up to 15 pounds. OCCASIONAL carry up to 25 pounds of various supplies including cans of paint, tool box, equipment and supplies. SELDOM carry between 25 and 50 pounds when moving a case of paper, furniture and other items out of vacated apartments. The distance items are carried may be from 50 to 100 feet. Elevators are available if items need lbs. to be moved to another floor. For items Based on F Page 3 of 8

120 Claimant: Claim No.: Job Title: Maintenance Body Part Injured: DOT Code: Job Demand Frequency & Weight Activity Description weighing over 50 pounds there is assistance available or a hand truck/dolly can be used. Pushing/ Pulling (Dist.) ft lbs. of force OCCASIONAL pushing/pulling when moving furniture. Carts available for moving heavier equipment. Perform Work on Ladders Climb ladders when decorating, painting or performing other job duties. Climb Stairs Elevators are available along with stairs for emergency situations or at employee s discretion. Twisting OCCASIONAL twisting may occur at waist when performing carpentry work or working in tight spaces when repairing appliances. SELDOM twist at neck level when driving. Stooping / Bending FREQUENT bending occurs when repairing pipes under sinks, installing wall outlets, painting, assisting residents, and completing various work orders. Squatting / Kneeling OCCASIONAL crouching occurs when repairing pipes under sinks, installing wall outlets, painting and completing other work orders. Crawling SELDOM crawling when working under appliances and in tight spaces. Balancing Balance is needed when working on the ladder. (Left/Right/Both) Reach Waist to Shoulder FREQUENT reaching between shoulder and waist height when painting or performing tasks required for maintenance. Work Above Shoulders FREQUENT reaching above shoulder height when changing light bulbs, painting walls or ceiling and when climbing ladders. FREQUENT reaching below waist height when performing maintenance tasks on toilets and sinks, performing electrical testing and to obtain supplies. Keyboarding To access and document information. Wrist Flexion/Extension To perform some job duties. Handle/Grasp CONSTANT handling of various tools and supplies during daily job tasks. Forceful Grasp Forceful grasp is intermittent when using hand tools, moving furniture and performing repairs. Fine Finger Manipulation OCCASIONAL fine finger manipulation while working on wiring, manipulating small parts for repairs and/or to complete projects and paperwork. Based on F Page 4 of 8

121 Claimant: Claim No.: Job Title: Maintenance Body Part Injured: DOT Code: Hand Controls OCCASIONALLY operate hand and foot controls when using vehicles, power tools or testing equipment. Foot Controls OCCASIONALLY operate hand and foot controls when using vehicles, power tools or testing equipment. Repetitive Motion Body part: Hands/Arms For various job duties. Vibratory Tasks - Low May be some whole body vibration when operating equipment. Vibratory Tasks - High Talking Necessary for communicating and taking instruction from others. Hearing Necessary for communicating and taking instruction from others. Tasting/Smelling Smell required when evaluating electrical and plumbing repair needs. Taste not a requirement for this position. Visual - Near Acuity Necessary for doing the job effectively and correctly. Visual - Far Acuity While driving or performing various repairs. Visual - Depth Perception While driving or performing various repairs. Visual - Color Discrimination When working with wiring or performing other tasks. Visual - Accommodation Visual - Field Of Vision When driving and performing a variety of other tasks. Environmental Conditions Frequency Activity Description Exposure to Weather 20% is performed outdoors Extreme Cold Extreme Hot Wet and / or Humidity During inclement weather. Proximity to Moving Mechanical Parts When working with some equipment. Exposure to Explosives Atmospheric Conditions Exposed Heights When working on a ladder. Exposure to Electricity When performing electrical repairs. Exposure to Toxic / Caustic Chemicals Exposure to paint, paint thinner and other maintenance chemicals may occur. May be exposed to some infectious diseases and cleaning agents. Exposure to Radiation Other: Noise Intensity 1 = Very Quiet, 2 = Quiet, 4 3 = Moderate, 4 = Loud, 5 = Very Loud Based on F Page 5 of 8

122 Claimant: Claim No.: Job Title: Maintenance Body Part Injured: DOT Code: Based on F Page 6 of 8

123 Claimant: Claim No.: Job Title: Maintenance Body Part Injured: DOT Code: Analyst s Comments: Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 7 of 8

124 Claimant: Claim No.: Job Title: Maintenance Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 8 of 8

125 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Medical Records Clerk DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Medical Records Clerk Brief Job Description/Duties: Compiles, verifies, types, and files medical records of health care facility. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. 30 lbs. lbs. 10 lbs. lbs. Carry lbs. lbs. 10 lbs. lbs. lbs. Push / Pull lbs. 10 lbs. lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

126 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Medical Records Clerk DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Medical Records Clerk DOT Title: Medical-Record Clerk SVP: 4 DOT #: Wage: Type of Industry: 573, Medical Service Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Medical Records Clerk DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Compiles, verifies, types, and files medical records of health care facility. Essential Job Functions: Responsible for medical records information on each individual resident and incorporating the nursing staff information into these records. Process computerized resident plan of care and multidisciplinary flowsheets, updating, printing and distributing care plan flowsheets and problem sheets. Review charts of discharged residents for deficiencies and monitore to ensure compliance for correction of deficient documentation. Coordinate and fill in chronological order each section of the residents record. May be required to send charts. Maintain effective communication with others, both inside and outside the department to give or obtain needed information or coordinate activities of residents. Training/Preparation Required: Over 3 months, up to 6 months. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Computer and telephone. Based on F Page 2 of 6

127 Claimant: Claim No.: Job Title: Medical Records Clerk Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting Frequent sitting at a desk and computer to input and update information. Standing Occasional standing and walking is performed on a variety of floor surfaces including carpeting, linoleum and tile. Walking Occasional walking and standing is performed on a variety of floor surfaces including carpeting, linoleum and tile. Job Demand Frequency & Weight Activity Description Lifting Carry (Dist.) 100 ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force Lift up to 10 pounds of files, charts, office materials and supplies. Lift a box of records and supplies up to 30 pounds. Occasionally carry resident charts from one location to another a distance of 100 feet, depending upon the facility size. When transferring several charts a rolling cart can be utilized. Rare pushing/pulling when opening and closing desk drawers or moving a cart filled with medical records from one location to another. Perform Work on Ladders Climb Stairs Twisting Stooping / Bending Occasional bending/stooping when retrieving charts or supplies from lower shelves. Squatting / Kneeling Crawling Balancing Based on F Page 3 of 6

128 Claimant: Claim No.: Job Title: Medical Records Clerk Body Part Injured: DOT Code: (Left/Right/Both) Reach Waist to Shoulder Reach between shoulder and waist height when documenting information and compiling paperwork. Occasional reaching below waist while retrieving resident charts from lower shelves. Work Above Shoulders Reach above shoulder height when retrieving medical charts from upper shelves. Reach below waist while retrieving resident charts from lower shelves. Keyboarding To record and process information. Wrist Flexion/Extension While keyboarding. Handle/Grasp Handle medical charts, office supplies. Forceful Grasp To lift items. Fine Finger Manipulation Fingering when keyboarding. Hand Controls Intermittent use of hand controls on the computer and the telephone. Foot Controls Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking Necessary for communicating and taking instruction from doctors and supervisor. Hearing Necessary for communicating and taking instruction from doctors and supervisor. Tasting/Smelling Taste and Smell are not requirements for this position. Visual - Near Acuity Necessary for doing the job effectively and correctly. Visual - Far Acuity Visual - Depth Perception Visual - Color Discrimination Visual - Accommodation Visual - Field Of Vision Environmental Conditions Exposure to Weather Extreme Cold Extreme Hot Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Frequency Activity Description Based on F Page 4 of 6

129 Claimant: Claim No.: Job Title: Medical Records Clerk Body Part Injured: DOT Code: Environmental Conditions Frequency Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud Analyst s Comments: Possible Employer Modifications: 2 Activity Description May be exposed to some infectious diseases and cleaning agents. Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

130 Claimant: Claim No.: Job Title: Medical Records Clerk Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

131 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: NAC - Nursing Home DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Nurse Assistant Certified (NAC) - Nursing Home Brief Job Description/Duties: Provide direct care to nursing home residents, primarily for their activities of daily living but also to include some nursing care. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs lbs lbs lbs. 5 lbs. Carry lbs. lbs. 15 lbs. 5 lbs. lbs. Push / Pull lbs. 35 lbs. 25 lbs. 10 lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 8 Index: VOC

132 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Nurse Assistant Certified (NAC) - Nursing Home DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Nurse Assistant Certified (NAC) - Nursing Home DOT Title: Nurse Assistant SVP: 4 DOT #: Wage: Type of Industry: 573 Medical Services Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: NAC - Nursing Home DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Provide direct care to nursing home residents, primarily for their activities of daily living but also to include some nursing care. Essential Job Functions: Assist residents in and out of bed and into wheelchair with the correct use of the transfer belt (may require the assistance of another aid depending on weight and physical/cognitive abilities of resident). Assist residents in bathing. Assist residents in dressing and undressing. Assist residents in using bathroom facilities and peri care. May be required to assist in personal grooming of residents (i.e. brush hair, trim finger nails and toe nails). Take vital signs of residents (i.e. temperature and blood pressure) and record information. Assist residents to dining area for meals. May be required to assist in feeding residents and documenting intake of nourishment. May strip bedding and replace with clean linens. If resident is bedridden due to illness, aid may be required to turn resident intermittently. May be required to clean bedpans and empty catheter bags. Required to document information regarding the each resident's health, input/output and any change of medical condition. Must be able to perform CPR. Training/Preparation Required: Nurse Assistant Certification and associated credentials necessary to work in a nursing home. High school diploma/ged required. Must be able to pass background check. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Blood pressure cuff, medical supplies, Vera Lift and Vander Lift and bathing chairs. Based on F Page 2 of 8

133 Claimant: Claim No.: Job Title: NAC - Nursing Home Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting OCCASIONAL sitting for periods up to minutes at a time while feeding residents, visiting with residents and charting. Sitting typically does not occur more than one hour total each shift. Standing FREQUENT standing throughout the work day. Static standing occurs for periods up to 5 minutes at one time. Dynamic standing occurs for periods up to 15 minutes. Floor surfaces are generally carpet, linoleum, tile or concrete. Static and dynamic standing combined with walking occur CONSTANTLY throughout the work day. Standing positions are alternated on a frequent basis. Walking FREQUENT walking in assigned work area on carpeted, linoleum and tile floors. Walk combined with dynamic and static stand occur CONSTANTLY. Job Demand Frequency & Weight Activity Description Lifting CONSTANT - up to 5 pounds of residents personal items (i.e. clothing, food items, medical charts, notebooks, linens and supplies). FREQUENT 5 to 10 pounds of supplies and equipment. OCCASIONAL - up to 50 pounds when lifting heavier equipment and when transferring a resident or when assisting a resident in bathing or dressing. Employer states typically two aids are utilized when resident is unusually heavy lbs. or combative. Carry FREQUENTLY carry up to 5 pounds of a (Dist.) ft residents personal items (i.e., clothing, food items, medical charts). OCCASIONALLY carry 15 pounds (trays, linens and medical equipment). Carts are used to move items weighing more than lbs. 15 pounds. Based on F Page 3 of 8

134 Claimant: Claim No.: Job Title: NAC - Nursing Home Body Part Injured: DOT Code: Job Demand Frequency & Weight Activity Description Pushing/ Pulling (Dist.) ft. N S 35 O 25 F 10 C lbs. of force FREQUENT push/pull empty Vander-Lift and Vera-Lift to individual rooms as needed. FREQUENT push/pull cart with medical equipment and supplies requiring up to 10 pounds of force. SELDOM push/pull cart loaded with heavier supplies requiring push/pull force up to 25 pounds. Typically cart rolls easily over concrete walkways, carpeting and tile. Push wheelchairs on a OCCASIONAL basis. In regards to pushing wheelchairs the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. Each employee performs CPR on a SELDOM basis. CPR is needed 1-2 times per week throughout the facility and multiple employees perform this function. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives typically 1-4 minutes. Perform Work on Ladders Climb Stairs Twisting OCCASIONAL twisting may occur at the waist while transferring residents and performing other duties. Stooping / Bending OCCASIONAL bending occurs while taking vital signs, assisting residents in bathing, providing peri care, making beds, etc. Must be able to perform CPR. Squatting / Kneeling OCCASIONAL crouching/squatting may occur while bathing a resident. On a rare basis, may need to kneel or crouch to retrieve items at floor level or to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee s discretion. Crawling Balancing Must be able to balance when assisting residents with movement. Employee does not work at heights. Based on F Page 4 of 8

135 Claimant: Claim No.: Job Title: NAC - Nursing Home Body Part Injured: DOT Code: (Left/Right/Both) Reach Waist to Shoulder Waist to shoulder level FREQUENT when assisting residents in eating, changing bed linens, taking vital signs. Below waist level FREQUENT assisting residents with peri-care and bathing. As needed for reaching items located on lower shelves. Work Above Shoulders SELDOM when reaching for medical records or supplies located on shelves. Keyboarding To access/document information. Wrist Flexion/Extension While keyboarding. Handle/Grasp Employee will constantly grasp and handle grooming implements, blood pressure cuff, thermometer, clothing, medications and other related items. Handle/grasp activities are non-repetitive and intermittent. Forceful Grasp To perform various job duties. Fine Finger Manipulation OCCASIONAL fine finger manipulation occurs while documenting residents medical charts and as needed for buttons and laces when dressing. Also used for operating blood pressure cuff and other medical equipment. Hand Controls OCCASIONALLY use blood pressure gauge and thermometer, office equipment and other nursing/medical equipment. The use of both hand and foot controls is required (i.e. wheelchair brakes, hydraulic beds, etc). Foot Controls OCCASIONALLY use blood pressure gauge and thermometer, office equipment and other nursing/medical equipment. The use of both hand and foot controls is required (i.e. wheelchair brakes, hydraulic beds, etc). Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking The ability to speak and hear is necessary for communicating with residents and other aids and for taking instructions from Charge Nurse and requests from residents. Hearing The ability to speak and hear is necessary for communicating with residents and other aids and for taking instructions from Charge Nurse and requests from residents. Tasting/Smelling Must be able to detect emergencies and determine the cleanliness of residents. Visual - Near Acuity Employee must have good vision to perform job tasks. Based on F Page 5 of 8

136 Claimant: Claim No.: Job Title: NAC - Nursing Home Body Part Injured: DOT Code: Visual - Far Acuity Employee must have good vision to perform job tasks. Visual - Depth Perception To perform various job duties. Visual - Color To perform various job duties. Discrimination Visual - Accommodation To perform various job duties. Visual - Field Of Vision To perform various job duties. Environmental Conditions Exposure to Weather Extreme Cold Extreme Hot Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity Frequency 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud 2 Activity Description Will be exposed to household and hospital chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry. May use mask, goggles and gowns. Analyst s Comments: Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 6 of 8

137 Claimant: Claim No.: Job Title: NAC - Nursing Home Body Part Injured: DOT Code: Based on F Page 7 of 8

138 Claimant: Claim No.: Job Title: NAC - Nursing Home Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 8 of 8

139 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Nurse Manager DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Nurse Manager Brief Job Description/Duties: Responsible for assessment, planning, coordination, implementation and evaluation of elderly and/or end of life patients. Manage floor staff, complete scheduling, hiring, interviewing and counseling. Deal with physicians, hospice groups, the State, care plans and plans of correction. This is an administrative role with very little direct patient care. Population of patients is predominantly elderly - both transitional and long term care provided. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. lbs. 5 lbs. lbs. lbs. Carry lbs. lbs. 5 lbs. lbs. lbs. Push / Pull lbs. 5 lbs. lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

140 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Nurse Manager DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Nurse Manager DOT Title: Nurse Consultant SVP: 7 DOT #: Wage: Type of Industry: Medical Services Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Nurse Manager DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Responsible for assessment, planning, coordination, implementation and evaluation of elderly and/or end of life patients. Manage floor staff, complete scheduling, hiring, interviewing and counseling. Deal with physicians, hospice groups, the State, care plans and plans of correction. This is an administrative role with very little direct patient care. Population of patients is predominantly elderly - both transitional and long term care provided. Essential Job Functions: Assess, plan, coordinate, implement and evaluate elderly and/or end of life patients. Manage floor staff, complete scheduling, hiring, interviewing and counseling. Deal with physicians, hospice groups, the State, care plans and plans of correction. Training/Preparation Required: RN or LPN with current, valid state license. Supervisor/Manager experience is required. Must pass background check. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Telephone, laptop, printer, keyboard, mouse, printer, copier and other office equipment. Some nursing equipment and supplies. Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week Based on F Page 2 of 6

141 Claimant: Claim No.: Job Title: Nurse Manager Body Part Injured: DOT Code: % Time Sitting Sitting, standing and walking are alternated. Standing Standing, sitting and walking are alternated. Walking Walking, sitting and standing are alternated. Job Demand Frequency & Weight Activity Description Lifting Carry (Dist.) ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force Office supplies and nursing supplies. Office supplies and nursing supplies To open/close drawers, to perform clinical assessment, and to move equipment. Perform Work on Ladders Climb Stairs Twisting Stooping / Bending To reach supplies or perform clinical assessment. Squatting / Kneeling Crawling Balancing (Left/Right/Both) Reach Waist to Shoulder To reach supplies or perform clinical assessment. To perform keyboarding. Work Above Shoulders To reach supplies. Keyboarding To document and access information. Wrist Flexion/Extension While keyboarding. Handle/Grasp Office supplies, assessment tools. Forceful Grasp To perform various job duties. Fine Finger Manipulation To perform various job duties. Hand Controls Operate office equipment. Foot Controls Raise/lower beds. Repetitive Motion Body part: Upper extremities Keyboarding Vibratory Tasks - Low Vibratory Tasks - High Based on F Page 3 of 6

142 Claimant: Claim No.: Job Title: Nurse Manager Body Part Injured: DOT Code: Talking Must be able to effectively communicate. Hearing Must be able to detect danger and effectively communicate. Tasting/Smelling Must be able to detect cleanliness. Visual - Near Acuity Must be able to read documents. Visual - Far Acuity Must be able to navigate facility. Visual - Depth Perception Visual - Color Discrimination To perform various job duties. Visual - Accommodation Visual - Field Of Vision To perform various job duties. Environmental Conditions Frequency Activity Description Exposure to Weather Work is performed predominantly indoors. Extreme Cold Extreme Hot Wet and / or Humidity During inclement weather. Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals May be exposed to household and hospital chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry. May use mask, goggles and gowns. Exposure to Radiation Other: Blood borne pathogens Minimal patient contact. Noise Intensity 1 = Very Quiet, 2 = Quiet, 2 Analyst s Comments: 3 = Moderate, 4 = Loud, 5 = Very Loud Possible Employer Modifications: Based on F Page 4 of 6

143 Claimant: Claim No.: Job Title: Nurse Manager Body Part Injured: DOT Code: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

144 Claimant: Claim No.: Job Title: Nurse Manager Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

145 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: NAC - Assisted Living DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Nurses Aid Certified (NAC) - Assisted Living Brief Job Description/Duties: Assist residents who are lucid, ambulatory and non-combative with activities of daily living. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. lbs. 20 lbs. 10 lbs. 5 lbs. Carry lbs. lbs. 15 lbs. 5 lbs. lbs. Push / Pull lbs. 35 lbs. 25 lbs. 10 lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 7 Index: VOC

146 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Nurses Aid Certified (NAC) - Assisted Living DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Nurses Aid Certified (NAC) - Assisted Living DOT Title: Nurse Assistant SVP: 4 DOT #: Wage: Type of Industry: 573 Medical Services Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: NAC - Assisted Living DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Assist residents who are lucid, ambulatory and non-combative with activities of daily living. Essential Job Functions: Assist residents in bathing, dressing/undressing, and personal grooming. Assist ambulatory residents in and out of bed by assisting them with lifting their feet only. Dispense predosed medications to residents. Take vital signs such as blood pressure and temperature and record information. Assist residents to dining areas for meals and assist in basic meal preparation and clean-up. Assist with changing bed sheets, laundry, storage of clothes/linens, and light dusting/vacuuming. Must be able to perform CPR. Training/Preparation Required: Nurse Assistant Certification and associated credentials necessary to work in a nursing home. High school diploma/ged required. Must be able to pass background check. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Blood pressure cuff, thermometer, and grooming implements. Based on F Page 2 of 7

147 Claimant: Claim No.: Job Title: NAC - Assisted Living Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting OCCASIONAL sitting for periods up to minutes at a time while feeding residents, visiting with residents and charting. Sitting typically does not occur more than one hour total each shift. Standing FREQUENT standing throughout the work day. Static standing occurs for periods up to 5 minutes at one time. Dynamic standing occurs for periods up to 15 minutes. Floor surfaces are generally carpet, linoleum, tile or concrete. Static and dynamic standing combined with walking occur CONSTANTLY throughout the work day. Standing positions are alternated on a frequent basis. Walking FREQUENT walking in assigned work area on carpeted, linoleum and tile floors. Walk combined with dynamic and static stand occur CONSTANTLY. Job Demand Frequency & Weight Activity Description Lifting Employee occasionally lifts items weighing up to 20 pounds, such as clothing, food, medical charts, supplies, grooming implements, linens, medications and equipment. Employee frequently lifts items weighing up to 10 pounds. All residents in this facility are ambulatory and patient transfers are not required. If a resident falls, employees contact 911 for assistance. Employee may assist patients in getting in/out of bed or in/out of bath chair, which will not lbs. require lifting more than 20 pounds Carry Employee may occasionally carry items (Dist.) ft weighing up to 15 pounds and frequently lbs. carry items weighing up to 5 pounds. Pushing/ Pulling (Dist.) ft. N S 35 O 25 F 10 C lbs. of force FREQUENT push/pull cart with medical equipment and supplies requiring up to 10 pounds of force. SELDOM push/pull cart loaded with heavier supplies Based on F Page 3 of 7

148 Claimant: Claim No.: Job Title: NAC - Assisted Living Body Part Injured: DOT Code: Job Demand Frequency & Weight Activity Description requiring push/pull force up to 25 pounds. Typically cart rolls easily over concrete walkways, carpeting and tile. Push wheelchairs on a OCCASIONAL basis. In regards to pushing wheelchairs the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. Each employee performs CPR on a SELDOM basis. CPR is needed 1-2 times per week throughout the facility and multiple employees perform this function. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives typically 1-4 minutes. Perform Work on Ladders Climb Stairs Twisting Employee occasionally twists at the waist while assisting residents with daily living tasks. Stooping / Bending Employee occasionally bends at waist when assisting residents with daily living tasks, performing light housekeeping duties or when preparing food. Employee must be able to perform CPR. Squatting / Kneeling Employee occasionally crouches when assisting residents with daily living tasks. On a rare basis, may need to kneel or crouch to retrieve items at floor level or to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee s discretion. Crawling Balancing Must be able to balance when assisting residents with movement, employee does not work at heights. Based on F Page 4 of 7

149 Claimant: Claim No.: Job Title: NAC - Assisted Living Body Part Injured: DOT Code: (Left/Right/Both) Reach Waist to Shoulder Employee frequently reaches (non-weight bearing) with ¾ to full arm extension in all directions when assisting residents in daily living tasks. Work Above Shoulders When reaching for medical records, dishes and supplies located on shelves. Keyboarding To access/document information. Wrist Flexion/Extension While keyboarding. Handle/Grasp Employee will constantly grasp and handle grooming implements, blood pressure cuff, thermometer, clothing, medications and other related items. Handle/grasp activities are non-repetitive and intermittent. Forceful Grasp To perform various job duties. Fine Finger Manipulation Employee occasionally and intermittently uses fine finger manipulation when working with residents and recording/charting information. Hand Controls Employee may operate hand controls on office equipment or household/cleaning type equipment. May also operate hand controls on nursing equipment. Foot Controls The use of both hand and foot controls is required (i.e. wheelchair brakes, hydraulic beds, etc). Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking Good speaking and listening abilities are necessary, and the employee must be able to effectively communicate in the English Language with co-workers and residents. Hearing Good speaking and listening abilities are necessary, and the employee must be able to effectively communicate in the English Language with co-workers and residents. Tasting/Smelling Employee should be able to smell to discern if a resident is incontinent or to detect smoke, etc. Visual - Near Acuity Employee must have good vision to perform job tasks. Visual - Far Acuity To navigate facility. Visual - Depth Perception To perform various job duties. Visual - Color Discrimination To perform various job duties. Visual - Accommodation To perform various job duties. Visual - Field Of Vision CONSTANT for doing job effectively and correctly. Based on F Page 5 of 7

150 Claimant: Claim No.: Job Title: NAC - Assisted Living Body Part Injured: DOT Code: Environmental Conditions Exposure to Weather Extreme Cold Extreme Hot Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity Frequency 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud 2 Activity Description Will be exposed to household and hospital chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry. May use mask, goggles and gowns. Analyst s Comments: Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 6 of 7

151 Claimant: Claim No.: Job Title: NAC - Assisted Living Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 7 of 7

152 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Physical Therapy Assistant DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Physical Therapy Assistant Brief Job Description/Duties: Prepares patients for physical therapy treatments and provides assistance to physical therapist. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. lbs lbs. 15 lbs. lbs. Carry lbs. lbs. 15 lbs. 5 lbs. lbs. Push / Pull lbs. lbs. 25 lbs. 15 lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

153 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Physical Therapy Assistant DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Physical Therapy Assistant DOT Title: Physical Therapy Aide SVP: 4 DOT #: Wage: Type of Industry: 573, Medical Services Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Physical Therapy Assistant DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Prepares patients for physical therapy treatments and provides assistance to physical therapist. Essential Job Functions: Assists residents from room to physical therapy, either by wheelchair or walking with ambulatory residents. Required to transfer residents prior to performing various exercises with the resident. May utilize the assistance of another aid if necessary. Assist residents with range of motion exercises, walking and light aerobic activities. Document progress of individual residents. Assist physical therapist in administering treatments, tests and evaluations of elderly residents. Must be physically able to tolerate physical exertion. Must be able to demonstrate and participate with the residents in light aerobic exercises or range of motion exercises. Training/Preparation Required: Over 3 months, up to 6 months. Must meet certification requirements. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Gym equipment, computer and telephone. Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week Based on F Page 2 of 6

154 Claimant: Claim No.: Job Title: Physical Therapy Assistant Body Part Injured: DOT Code: % Time Sitting Occasional sitting, from one to two hours per day usually while documenting information regarding residents. Standing Occasional standing, up to three hours per day on various surfaces (carpet, linoleum or tile); alternated with walking. Walking Occasional walking, up to three hours per day on various surfaces (carpet, linoleum or tile); alternated with standing. Job Demand Frequency & Weight Activity Description Lifting Carry (Dist.) ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force Lift up to 10 pounds when assisting resident in performing range of motion activities. Occasional lift of 25 pounds and up to 50 pounds when transferring residents (2 person lift). Various physical therapy items. Pushing/pulling occurs transporting residents in wheelchairs. Pushing/pulling for range of motion exercises or to use equipment. Perform Work on Ladders Climb Stairs May demonstrate climbing short set of steps in therapy room. Twisting Occasional twisting may occur while demonstrating exercises to residents. Stooping / Bending Frequent bending/stooping is performed while assisting residents with exercises. Squatting / Kneeling Occasional crouching/squatting occurs while assisting residents with exercises. Crawling Balancing Must be able to balance when transferring a resident or assisting them with exercised. (Left/Right/Both) Reach Waist to Shoulder When working with residents. Based on F Page 3 of 6

155 Claimant: Claim No.: Job Title: Physical Therapy Assistant Body Part Injured: DOT Code: Work Above Shoulders Reaching at and above shoulder height while assisting residents with range of motion exercises or light aerobic exercises. Reaching below shoulder height also occurs while assisting with range of motion exercises. Keyboarding To access and document information. Wrist Flexion/Extension While keyboarding. Handle/Grasp Frequent handling is used while assisting residents with exercises. Frequent grasping is used when documenting progress of residents. Forceful Grasp To assist residents and to lift heavy items. Fine Finger Manipulation Occasional fine finger manipulation is used while documenting progress of resident. Some facilities may utilize a computer for charting. Hand Controls Occasional use of limited hand controls to flip a switch, push a button, etc. Foot Controls Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking The ability to talk/hear is necessary for communicating with the residents and other aids and for taking instructions from physical therapist. Hearing The ability to talk/hear is necessary for communicating with the residents and other aids and for taking instructions from physical therapist. Tasting/Smelling Visual - Near Acuity Must be able to read and document information. Visual - Far Acuity Must be able to navigate facility. Visual - Depth Perception Must be able to navigate facility and assist residents safely. Visual - Color Discrimination To perform various job duties. Visual - Accommodation To perform various job duties. Visual - Field Of Vision Must be able to navigate facility and assist residents safely. Environmental Conditions Exposure to Weather Extreme Cold Extreme Hot Wet and / or Humidity Frequency Activity Description Based on F Page 4 of 6

156 Claimant: Claim No.: Job Title: Physical Therapy Assistant Body Part Injured: DOT Code: Environmental Conditions Frequency Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud Analyst s Comments: Possible Employer Modifications: 3 Activity Description May be exposed to some infectious diseases and cleaning solutions. Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

157 Claimant: Claim No.: Job Title: Physical Therapy Assistant Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

158 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Receptionist DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Receptionist Brief Job Description/Duties: Greets and directs visitors and residents within the facility. Answers and directs all calls coming into the facility's main switch board. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. lbs. 10 lbs. 2 lbs. lbs. Carry lbs. lbs. 10 lbs. lbs. lbs. Push / Pull lbs. lbs. 2 lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

159 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Receptionist DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Receptionist DOT Title: Receptionist SVP: 4 DOT #: Wage: Type of Industry: 249, Clerical and Kindred Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Receptionist DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Greets and directs visitors and residents within the facility. Answers and directs all calls coming into the facility's main switch board. Essential Job Functions: Assist all visitors that come into the facility. Know the proper procedures for fire drills and will notify security of any problems. May deliver packages, flowers, etc. to residents as needed. Distribute mail in mail room to residents' mail slots and staff mail boxes. Other clerical duties related to mail distribution. Training/Preparation Required: Over 3 months, up to 6 months of training/experience. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Computer, phone system, and public announcement system. Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week Based on F Page 2 of 6

160 Claimant: Claim No.: Job Title: Receptionist Body Part Injured: DOT Code: % Time Sitting Sit for six to seven hours out of an eight hour work day using a counter level surface and an office chair. Standing Occasional standing and walking, approximately one to two hours per shift. Walking Occasional standing and walking, approximately one to two hours per shift. Job Demand Frequency & Weight Activity Description Lifting Carry (Dist.) 100 ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force Occasionally lift deliveries for residents weighing no more than five to 10 pounds. Occasionally lift deliveries for residents weighing no more than five to 10 pounds and potentially carry these items for up to 100 feet at a time. Intermittent pushing and pulling to open/close doors and drawers may be necessary. Perform Work on Ladders Climb Stairs Twisting Stooping / Bending Rare bending may be used when retrieving dropped items from drawers. Squatting / Kneeling Crawling Balancing (Left/Right/Both) Reach Waist to Shoulder While keyboarding, answering the phone, sorting mail. Work Above Shoulders Occasional reaching above shoulder height when distributing mail. Occasionally reaching below shoulder height when retrieving supplies. Keyboarding To document and access information. Wrist Flexion/Extension While keyboarding. Handle/Grasp Frequent handling and grasping when writing messages, sorting mail, etc. Forceful Grasp To pick up items. Fine Finger Manipulation Occasional to frequent fingering will be used when keyboarding. Based on F Page 3 of 6

161 Claimant: Claim No.: Job Title: Receptionist Body Part Injured: DOT Code: Hand Controls Intermittent use of the hand controls on the telephone, headset, computer, public announcement system. Foot Controls Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking The ability to speak and hear is constantly required when communicating with others and when communicating with residents and visitors. Hearing The ability to speak and hear is constantly required when communicating with others and when communicating with residents and visitors. Tasting/Smelling Visual - Near Acuity Necessary to read information. Visual - Far Acuity When monitoring the outgoing and incoming visitors and residents. Visual - Depth Perception Visual - Color Discrimination Visual - Accommodation Visual - Field Of Vision When monitoring the outgoing and incoming visitors and residents. Environmental Conditions Exposure to Weather Extreme Cold Extreme Hot Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity Frequency 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud 2 Activity Description May be exposed to some infectious diseases and cleaning agents. Based on F Page 4 of 6

162 Claimant: Claim No.: Job Title: Receptionist Body Part Injured: DOT Code: Analyst s Comments: Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

163 Claimant: Claim No.: Job Title: Receptionist Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

164 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Therapy Assistant DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Recreation/Activities Therapy Assistant Brief Job Description/Duties: Perform duties involving the planning and implementation of activities/programs, which meet the needs and interests for the physical, mental and psycho-social well-being of the residents; i.e., horticulture classes, group exercises, crafts and woodworking. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs lbs. 10 lbs. lbs. lbs. Carry lbs. lbs. 10 lbs. lbs. lbs. Push / Pull lbs. lbs. 25 lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

165 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Recreation/Activities Therapy Assistant DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Recreation/Activities Therapy Assistant DOT Title: Recreational Therapist SVP: 6 DOT #: Wage: Type of Industry: 573, Medical Services Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Therapy Assistant DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Perform duties involving the planning and implementation of activities/programs, which meet the needs and interests for the physical, mental and psycho-social well-being of the residents; i.e., horticulture classes, group exercises, crafts and woodworking. Essential Job Functions: Maintain documentation as required by the State and Federal regulations. Assist with resident outings; may operate van. Coordinate and instruct participation of volunteers with residents. May be required to care for facility pets; i.e., dogs, cats, fish and birds. Assist in maintenance of recreation equipment and supplies. This is a somewhat physical position based on the required amount of walking and standing. Transferring of patients does not occur often but employee is required to know the correct way to transfer residents so as not to injure the resident or themselves. Typically there is more than one Recreation Therapy Assistant available. Training/Preparation Required: Over 1 year up to 2 years of training/experience. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Operate a van, use paints brushes, and other craft supplies. Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time Based on F Page 2 of 6

166 Claimant: Claim No.: Job Title: Therapy Assistant Body Part Injured: DOT Code: O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting Sitting occurs when driving the van and while documenting information regarding the residents. May sit for one to two hours per work day. Standing Standing and walking are alternated throughout the work day. Walking Walking and standing are alternated throughout the work day. Job Demand Frequency & Weight Activity Description Lifting Carry (Dist.) 50 ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force Occasional lifting up to 10 pounds to lift various supplies used in recreational activities; i.e., paints, brushes, etc. Rare lifting of 11 to 50 pounds of supplies, tables, chair, etc. Rare lifting over 50 pounds to transfer resident from wheelchair with the assistance of others. Use of a transfer belt is required. Occasional carrying up to 10 pounds to lift and carry supplies used for recreation activities. Carrying over 10 pounds is not required. Occasional pushing/pulling when assisting residents to recreation hall while resident is seated in wheelchair. Perform Work on Ladders May use short ladder or step stool to hang decorations, etc. Climb Stairs Rarely climb stairs or short stool to obtain items on higher shelves. Twisting Twisting at the waist to perform job duties. Twisting at neck level while driving. Stooping / Bending Frequent bending/stooping while working with seated residents at a table. The worker may bend over at the waist to monitor progress of resident. Squatting / Kneeling Frequent crouching/squatting is used while working with seated residents at a table. Crouching/squatting may be replaced by sitting or kneeling at the worker's discretion. Crawling Balancing Must be able to balance if transferring a resident. Based on F Page 3 of 6

167 Claimant: Claim No.: Job Title: Therapy Assistant Body Part Injured: DOT Code: (Left/Right/Both) Reach Waist to Shoulder Frequently reaching between shoulder and waist height when directing or demonstrating activity. Frequent reaching below waist height during the course of day when assisting with residents. Work Above Shoulders Occasional reaching above shoulder height to reach items on shelves for various supplies. Keyboarding To access or document information. Wrist Flexion/Extension When keyboarding or performing craft projects. Handle/Grasp Handle/grasp during the course of the day while documenting and working with hobbies or crafts Forceful Grasp Forceful grasping is used when performing some tasks and lifting heavy items. Fine Finger Manipulation Occasional use of fine finger manipulation during the course of day while assisting residents in the making of crafts. Hand Controls Occasionally use hand and foot controls when driving the van. Foot Controls Occasionally use hand and foot controls when driving the van. Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking The ability to speak and hear is constantly required during course of day to communicate with residents and other workers. Hearing The ability to speak and hear is constantly required during course of day to communicate with residents and other workers. Tasting/Smelling To detect cleanliness and safety hazards. Visual - Near Acuity To perform crafts. Visual - Far Acuity To drive vehicle and navigate facility. Visual - Depth Perception To drive vehicle. Visual - Color Discrimination To perform crafts. Visual - Accommodation For various job duties. Visual - Field Of Vision To drive vehicle. Based on F Page 4 of 6

168 Claimant: Claim No.: Job Title: Therapy Assistant Body Part Injured: DOT Code: Environmental Conditions Frequency Activity Description Exposure to Weather Exposure to both outside. Extreme Cold Extreme Hot Wet and / or Humidity During inclement weather. Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals May be exposed to paints, paint thinner, and other craft type chemicals. May be exposed to infectious disease. Exposure to Radiation Other: Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 Analyst s Comments: 3 = Moderate, 4 = Loud, 5 = Very Loud Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

169 Claimant: Claim No.: Job Title: Therapy Assistant Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

170 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: RN - Assisted Living DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Registered Nurse (RN) - Wellness Nurse Assisted Living Brief Job Description/Duties: Provides health education, counseling and appropriate nursing services that assist residents in living their lives. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricte d Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs lbs lbs. 10 lbs. lbs. Carry lbs. lbs. 10 lbs. 5 lbs. lbs. Push / Pull lbs lbs. 10 lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 7 Index: VOC

171 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Registered Nurse (RN) - Wellness Nurse Assisted Living DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Registered Nurse (RN) - Wellness Nurse Assisted Living DOT Title: Nurse, General Duty SVP: 7 DOT #: Wage: Type of Industry: 573 Medical Services Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: RN - Assisted Living DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Provides health education, counseling and appropriate nursing services that assist residents in living their lives. Essential Job Functions: In conjunction with the LPN Wellness Nurse, completes resident assessments prior to resident move in, 30 days after resident move in, semiannually and when there is a change in condition. Functions as a health counselor and provides health education for residents. Communicates with resident's family and Doctors on health-related issues. Based on assessment, develops with the Director, the resident, the resident's family (when appropriate) and staff a Service Package for each resident. When appropriate, provides direct nursing services and assistance to residents. Works closely with the Director to oversee staff development (Resident Service Associate initial and ongoing training) and supervision. In conjunction with the Director, oversees the Quality Assurance Program. Prepares incident reports and communicates related information to families. Monitors and oversees Medication Assistance Program. Performs other duties as assigned by management to meet changing job related requirements. Training/Preparation Required: Current Washington State RN License including current necessary training under Washington State WAC regulations. At least one year of experience. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Blood pressure cuff, thermometer, stethoscope, gloves, telephone, transfer belt, computer and medical equipment/supplies. Based on F Page 2 of 7

172 Claimant: Claim No.: Job Title: RN - Assisted Living Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting While charting activities and medical information by computer and/or hand and communicating with families. Standing Intermittent with walking while making rounds and checking on residents. Floor surfaces are generally carpet, linoleum, tile or concrete. Walking Intermittent with standing while making rounds and checking on residents. Floor surfaces are generally carpet, linoleum, tile or concrete. Job Demand Frequency & Weight Activity Description Lifting Carry (Dist.) ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force FREQUENT lift of 0-10 pounds for resident files and individual medical supplies. Lifting up to 25 pounds required when stocking medical supplies. Lifting up to 50 pounds is rarely (1-2 time per month) required to assist or transfer residents. The correct use of a transfer belt is required to avoid injury to the resident or nurse. Lifting is performed from floor to shoulder level. Lifting over shoulder level is SELDOM. FREQUENT up to 5 ponds. OCCASIONAL up to 10 pounds when carrying resident treatment bag or other items. Carts are used for moving items weighing more than 10 pounds, such as medical equipment and supplies. OCCASIONAL push/pull cart with medical equipment and supplies requiring up to 10 pounds of force. SELDOM push/pull cart loaded with heavier supplies requiring push/pull force up to 25 pounds. Typically cart rolls easily over concrete walkways, carpeting and tile. Push wheelchairs on a SELDOM basis. In regards to pushing wheelchairs Based on F Page 3 of 7

173 Claimant: Claim No.: Job Title: RN - Assisted Living Body Part Injured: DOT Code: Job Demand Frequency & Weight Activity Description the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. CPR is performed on a SELDOM basis - on average 2-4 times per year. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives typically 1-4 minutes. Perform Work on Ladders Climb Stairs Twisting OCCASIONAL twisting at the waist may occur when providing medical treatments, assisting in transfer or when applying/changing daily bandages and leg wraps. Stooping / Bending Bending required when providing treatment to residents, administering medications, taking vital signs and assisting seated residents. Must be able to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee s discretion. Squatting / Kneeling On a rare basis, may need to kneel or crouch to retrieve items at floor level or to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee s discretion. Crawling Crawling is not a requirement of this position. Balancing Must be able to balance when assisting residents with movement, employee does not work at heights. (Left/Right/Both) Reach Waist to Shoulder Reaching FREQUENTLY at all levels from standing and seated positions up to full arm extension when administering to residents who are bedridden and seated, reaching for supplies and using phone, charting information. Work Above Shoulders When reaching for medical records, dishes and supplies located on shelves. Keyboarding To access and document information. Wrist Flexion/Extension While keyboarding. Based on F Page 4 of 7

174 Claimant: Claim No.: Job Title: RN - Assisted Living Body Part Injured: DOT Code: Handle/Grasp FREQUENT grasping when handling pens/pencils for documenting information into medical charts, when handling paperwork and while using various medical supplies/equipment (stethoscope, thermometer, medications, syringes, etc.). Forceful Grasp Forceful grasp used when pushing resident in wheelchair and performing some nursing duties. Fine Finger Manipulation OCCASIONAL fine finger manipulation while using the computer and telephone and when performing first aid and administering shots. Hand Controls OCCASIONAL intermittent use of various hand controls with knobs to turn, buttons to push and switches to flip as needed for blood pressure cuff and various other medical equipment. Foot Controls The use of foot controls is SELDOM. Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking Necessary for communicating with others, safety awareness and for taking instructions from physicians and supervisor. Must be able to communicate in English. Hearing Necessary for communicating with others, safety awareness and for taking instructions from physicians and supervisor. Must be able to communicate in English. Tasting/Smelling Smell is required and necessary to detect dangerous odors when providing wound treatment and performing health assessment. Visual - Near Acuity CONSTANT for doing job effectively and correctly. Visual - Far Acuity To navigate facility. Visual - Depth Perception To perform various job duties. Visual - Color Discrimination To perform various job duties. Visual - Accommodation To perform various job duties. Visual - Field Of Vision CONSTANT for doing job effectively and correctly. Environmental Conditions Exposure to Weather Extreme Cold Extreme Hot Frequency Activity Description Based on F Page 5 of 7

175 Claimant: Claim No.: Job Title: RN - Assisted Living Body Part Injured: DOT Code: Environmental Conditions Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity Analyst s Comments: Frequency 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud Possible Employer Modifications: 2 Activity Description Will be exposed to household chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry. Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 6 of 7

176 Claimant: Claim No.: Job Title: RN - Assisted Living Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 7 of 7

177 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: RN - Nursing Home DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Registered Nurse, Primary Care - Nursing Home Brief Job Description/Duties: The RN will direct, administer and record the care given to residents in an assigned section of the nursing facility. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs lbs lbs. 10 lbs. lbs. Carry lbs. lbs. 10 lbs. 5 lbs. lbs. Push / Pull lbs. 35 lbs. 25 lbs. 10 lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 7 Index: VOC

178 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Registered Nurse, Primary Care - Nursing Home DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Registered Nurse, Primary Care - Nursing Home DOT Title: Nurse, General Duty SVP: 7 DOT #: Wage: Type of Industry: 573 Medical Services Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: RN - Nursing Home DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: The RN will direct, administer and record the care given to residents in an assigned section of the nursing facility. Essential Job Functions: Documentating and directing the other nursing staff in performing care for the residents. Communicate with family members regarding the progress of the resident. Assist visiting physicians in rounds. Draw blood and obtain fluids to submit for lab work. May be required to complete intravenous infusion/injection. Record and issue appropriate medications. May be required to work with Alzheimer's residents who are not cooperative. Record and monitor all progress of residents and communicate with physicians. May be required to assist in passing out trays to residents in dining area and assist in feeding. Monitor work of other nursing staff in unit to ensure thoroughness. Required to use telephones to communicate with physicians, arrange for transportation for doctor appointments and contact families. Make rounds to ensure cleanliness and proper care to residents. Coordinate care of residents. Manage all NAC staff in section. Assist staff members according to needs. Follow set protocol in emergency situation. Training/Preparation Required: Current Washington State RN License including current necessary training under Washington State WAC regulations. At least one year of experience. Based on F Page 2 of 7

179 Claimant: Claim No.: Job Title: RN - Nursing Home Body Part Injured: DOT Code: Machine, Tools, Special Equipment, Personal Protective Equipment Used: Computer, telephone, gowns, goggles, gloves, masks, Accucheck (Blood Sugar), scale, blood pressure cuff, bladder scanner, pulse oximeter, thermometer, IV pumps, portable oxygen and various first aid supplies and equipment. Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting OCCASIONAL while charting activities and medical information by computer and/or hand, phoning doctors, taking orders and communicating with families. Standing OCCASIONAL standing intermittent with walking while making rounds and checking on residents. Employer states static stand up to 2 minutes at one time when administering treatments. Twice per week static standing is required up to 45 minutes for longer treatments. Floor surfaces are generally carpet, linoleum, tile or concrete. Walking FREQUENT walking intermittent with standing. Floor surfaces are generally carpet, linoleum, tile or concrete. Job Demand Frequency & Weight Activity Description Lifting FREQUENT lift up to 10 pounds for resident files and supplies. Lifting pounds OCCASIONALLY required for medical supplies/equipment. SELDOM lifting up to 50 pounds to assist and transfer residents with transfer belt. The correct use of a transfer belt is required to avoid injury to the resident or nurse. Vera Lift and Vander Lifts are used to minimize weight. Lifting primarily performed from floor to shoulder level. Lifting over lbs. shoulder level is SELDOM. Carry FREQUENT up to 5 pounds. (Dist.) ft OCCASIONAL 5-10 pounds to move lbs. items from one location in the facility to another. Carts are available for heavier supplies and/or equipment. Based on F Page 3 of 7

180 Claimant: Claim No.: Job Title: RN - Nursing Home Body Part Injured: DOT Code: Job Demand Frequency & Weight Activity Description Pushing/ Pulling (Dist.) ft. N S 35 O 25 F 10 C lbs. of force FREQUENT push/pull cart with medical equipment and supplies requiring up to 10 pounds of force. SELDOM push/pull cart loaded with heavier supplies requiring push/pull force up to 25 pounds. Typically cart rolls easily over concrete walkways, carpeting and tile. Push wheelchairs on an OCCASIONAL basis. In regards to pushing wheelchairs the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. Each employee performs CPR on a SELDOM basis. CPR is needed 1-2 times per week throughout the facility and multiple employees perform this function. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives typically 1-4 minutes. Perform Work on Ladders Climb Stairs Twisting OCCASIONAL twisting may occur while providing patient care. Stooping / Bending OCCASIONAL bending may occur when providing treatment to residents, administering medications, taking vital signs and assisting seated residents, etc. Must be able to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee s discretion. Squatting / Kneeling On a rare basis, may need to kneel or crouch to retrieve items at floor level or to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee s discretion. Crawling Balancing Must be able to balance when assisting residents with movement, employee does not work at heights. Based on F Page 4 of 7

181 Claimant: Claim No.: Job Title: RN - Nursing Home Body Part Injured: DOT Code: (Left/Right/Both) Reach Waist to Shoulder Reaching FREQUENTLY at all levels from standing and seated positions up to full arm extension when administering to residents who are bedridden and seated, reaching for supplies and using phone, charting information. Work Above Shoulders Above shoulder level OCCASIONAL when attending patients with tubes and IVs and to obtain supplies on shelves. Keyboarding To access and document information. Wrist Flexion/Extension While keyboarding. Handle/Grasp FREQUENT handling paperwork, pens/pencils, telephone and various medical supplies/equipment (i.e. stethoscope, thermometer, medications, syringes, etc). Forceful Grasp Forceful grasp used when pushing resident in wheelchair and performing some nursing duties. Fine Finger Manipulation OCCASIONAL fine finger manipulation while using the computer keyboard, writing, and when performing first aid, administering shots and medications. Hand Controls FREQUENT use of various hand controls with knobs to turn, buttons to push and switches to flip as needed for blood pressure cuff and various other medical equipment. Foot Controls The use of foot controls may be required for hydraulic beds, wheelchair brakes, etc. Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking Necessary for safety awareness and for communicating and taking instructions from physicians, labs, pharmacists, families and supervisor. Ability to read, write, and speak English. Hearing Necessary for safety awareness and for communicating and taking instructions from physicians, labs, pharmacists, families and supervisor. Ability to read, write, and speak English. Tasting/Smelling Smell is required and necessary to detect dangerous odors, provide wound treatment and to perform health assessment/diagnosis. Visual - Near Acuity Must be able to read labels, doctor s instructions, medication orders, charts and medical history. Visual - Far Acuity To navigate facility. Visual - Depth Perception To perform various job duties. Visual - Color Discrimination To perform various job duties. Based on F Page 5 of 7

182 Claimant: Claim No.: Job Title: RN - Nursing Home Body Part Injured: DOT Code: Visual - Accommodation To perform various job duties. Visual - Field Of Vision CONSTANT for doing job effectively and correctly. Environmental Conditions Exposure to Weather Extreme Cold Extreme Hot Wet and / or Humidity Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity Frequency 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud 2 Activity Description Will be exposed to household and hospital chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry. May use mask, goggles and gowns. Possible exposure to needle pricks. Analyst s Comments: Possible Employer Modifications: Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 6 of 7

183 Claimant: Claim No.: Job Title: RN - Nursing Home Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 7 of 7

184 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: RSA - Assisted Living DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Residential Service Associate (RSA) - Assisted Living Brief Job Description/Duties: Responsible for providing services that will support and assist residents in activities of daily living. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. 50 lbs. 20 lbs. 10 lbs. 5 lbs. Carry lbs. lbs. 15 lbs. 5 lbs. lbs. Push / Pull lbs. 35 lbs. 25 lbs. 10 lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 8 Index: VOC

185 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Residential Service Associate (RSA) - Assisted Living DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Residential Service Associate (RSA) - Assisted Living DOT Title: Nurse Assistant SVP: 4 DOT #: Wage: Type of Industry: 573 Medical Services Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: RSA - Assisted Living DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Responsible for providing services that will support and assist residents in activities of daily living. Essential Job Functions: Based on resident-negotiated service agreements, provides assistance with medication, dressing, grooming, showering, dining, toileting, incontinence management, transfers and mobility/ambulation. Prepares, serves and cleans up breakfast. Completes final meal preparation, meal set up, meal serving and meal clean up for lunch and dinner. Occasionally provides extra housekeeping and laundry services for residents based on their negotiated service agreement. Strips beds, washes sheets, towels once per week; cleans kitchen and mattress pads as needed. Provides housekeeping services for common areas (vacuuming, wipe down/sanitation, dishwashing, etc). Helps Activity Director and/or assists residents to group and individual activities designed to meet their needs, interests and capabilities. In cardiac/emergency situations first calls 911, then Wellness Nurse on staff. Reports to Wellness Nurse and works under little supervision. Performs other duties as assigned to meet changing job related requirements. Must be able to perform CPR. Training/Preparation Required: Nurse Assistant Certification and associated credentials necessary to work in a nursing home. High school diploma/ged required. Must be able to pass background check. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Cart, blood pressure cuff, basic medical supplies, gloves, scale, thermometer; transfer belt. Based on F Page 2 of 8

186 Claimant: Claim No.: Job Title: RSA - Assisted Living Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting Occasional sitting while charting activities and when talking with residents. Standing FREQUENT standing intermittent with walking is performed for up to two hours at a time while making rounds and checking on residents. Floor surfaces are generally carpet, linoleum, tile or concrete. Walking FREQUENT walking intermittent with standing is performed for up to two hours at a time while making rounds and checking on residents. Floor surfaces are generally carpet, linoleum, tile or concrete. Job Demand Frequency & Weight Activity Description Lifting Waist to Shoulder Level: CONSTANT up to 5 pounds of residents personal items (i.e. clothing, food items, medical charts and supplies). FREQUENT - up to 10 pounds. OCCASIONAL pounds of soiled bed linens, resident belongings, large size containers from food and supply delivery carts and when assisting a resident in bathing or dressing. SELDOM 21 pounds to 50 pounds. Employer states lifting up to 50 pounds when assisting or transferring a resident - occurs on average once per week. Below waist and above shoulder level: SELDOM up to 5 pounds for supplies and dishes located at lower and lbs. higher levels. Carry Carry up to 5 pounds of resident s (Dist.) ft personal items (i.e. laundered clothing, food items, medical charts and supplies). OCCASIONALLY carry 15 pounds when transporting laundry baskets and soiled lbs. bed linens to a utility area and when Based on F Page 3 of 8

187 Claimant: Claim No.: Job Title: RSA - Assisted Living Body Part Injured: DOT Code: Job Demand Frequency & Weight Activity Description moving supplies. Carts are used for moving items weighing more than 15 pounds. Pushing/ Pulling (Dist.) ft lbs. of force FREQUENT push/pull cart with supplies requiring up to 10 pounds of force. SELDOM push/pull cart loaded with heavier supplies requiring push/pull force up to 25 pounds. Typically cart rolls easily over concrete walkways, carpeting and tile. Push wheelchairs on an OCCASIONAL basis. In regards to pushing wheelchairs the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. CPR is performed on a SELDOM basis - on average 2-4 times per year. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives typically 1-4 minutes. Perform Work on Ladders Climb Stairs Twisting OCCASIONAL twisting at the waist while preparing food, vacuuming, doing laundry, transferring resident or assisting in daily living. Stooping / Bending OCCASIONAL bending at waist and neck while assisting resident in bathing, loading/unloading dish washer, loading/unloading laundry washer/drying and when performing light housework. Must able to perform CPR. Squatting / Kneeling OCCASIONAL crouching/squatting may occur while bathing and dressing a resident or using the washer and dryer. On a rare basis, may need to kneel or crouch to retrieve items at floor level or to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee s discretion. Crawling Based on F Page 4 of 8

188 Claimant: Claim No.: Job Title: RSA - Assisted Living Body Part Injured: DOT Code: Balancing Must be able to balance when assisting residents with movement, employee does not work at heights. (Left/Right/Both) Reach Waist to Shoulder Waist to shoulder level FREQUENT when assisting residents in changing bed linens, serving food, working in the kitchen, doing laundry and cleaning. Below waist level FREQUENT when assisting residents with dressing and bathing, performing kitchen duties, doing laundry and reaching items located in dishwasher and oven. Bilateral reach is required with 3/4 to full arm extension. Work Above Shoulders When reaching for medical records, dishes and supplies located on shelves. Keyboarding To access/document information. Wrist Flexion/Extension While keyboarding. Handle/Grasp CONSTANT grasping when handling residents personal items, eating utensils, kitchen equipment, household appliances and when preparing meals and doing laundry. Forceful Grasp OCCASIONAL forceful grasp used when pushing resident in wheelchair. Grasping for transferring patients occurs on an infrequent weekly basis. Fine Finger Manipulation OCCASIONAL fine finger manipulation occurs while documenting residents medical charts, administering daily medications and as needed for buttons and laces when dressing. Hand Controls OCCASIONAL intermittent use of various hand controls with knobs to turn, buttons to push and switches to flip as needed for laundry, kitchen and vitals. Foot Controls The use of foot controls is OCCASIONAL (i.e. brakes on wheelchairs, etc). Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking The ability to speak and hear is necessary for communicating with residents and other aids and for taking instructions from Wellness Nurse and requests from residents. Hearing The ability to speak and hear is necessary for communicating with residents and other aids and for taking instructions from Wellness Nurse and requests from residents. Based on F Page 5 of 8

189 Claimant: Claim No.: Job Title: RSA - Assisted Living Body Part Injured: DOT Code: Tasting/Smelling Smell is required and necessary to detect safety and sanitary odors. Visual - Near Acuity Employee must have good vision to perform job tasks. Visual - Far Acuity To navigate facility. Visual - Depth Perception To perform various job duties. Visual - Color Discrimination To perform various job duties. Visual - Accommodation To perform various job duties. Visual - Field Of Vision CONSTANT for doing job effectively and correctly. Environmental Conditions Frequency Activity Description Exposure to Weather Walking between different residential units and the office building will expose worker to weather conditions. Extreme Cold Extreme Hot Wet and / or Humidity During inclement weather. Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity Analyst s Comments: 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud Possible Employer Modifications: 2 Will be exposed to household chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry. May use mask, goggles and gowns. Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Based on F Page 6 of 8

190 Claimant: Claim No.: Job Title: RSA - Assisted Living Body Part Injured: DOT Code: Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 7 of 8

191 Claimant: Claim No.: Job Title: RSA - Assisted Living Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 8 of 8

192 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Security Guard DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Security Guard Brief Job Description/Duties: Protects facility property from damage or loss from fire, robbery, and other hazards. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. 20 lbs. 10 lbs. 3 lbs. lbs. Carry lbs. 20 lbs. 10 lbs. lbs. 3 lbs. Push / Pull lbs. 50 lbs. 5 lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

193 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Security Guard DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Security Guard DOT Title: Security Guard SVP: 3 DOT #: Wage: Type of Industry: 138, Any Industry Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Security Guard DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Protects facility property from damage or loss from fire, robbery, and other hazards. Essential Job Functions: Checks various doors to ensure locked through building complex. May be required to turn on outside and inside lights. Required to keep a log of all incidents during the course of shift. On a rare occasion this employee may be required to chase after trespassers but can call upon the assistance of the police if this should occur. Although this is a somewhat sedentary position with very light lifting, the employee may be required to restrain a trespasser on occasion. A hand-held radio is usually available to contact help if necessary. May operate vehicle to patrol property. Training/Preparation Required: Over 30 days up to 3 months. Ability to chase and restrain an individual. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Hand-held radio and telephone. Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week Based on F Page 2 of 6

194 Claimant: Claim No.: Job Title: Security Guard Body Part Injured: DOT Code: % Time Sitting Rare sitting, usually only while on breaks or when driving a vehicle. Standing Standing alternated with walking on surfaces of carpeting, linoleum, tile or concrete. Walking Walking alternated with standing on surfaces of carpeting, linoleum, tile or concrete. Job Demand Frequency & Weight Activity Description Lifting Carry (Dist.) 50 ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force Lift a hand-held radio weighing approximately 3-pounds. Pick up litter on the grounds, weighing less than one pound. Rarely lift and deliver parcels to residents, which do not exceed 20- pounds. May rarely need to restrain a trespasser. Usually, the worker will call for assistance from police. Carry a 3-pound hand-held radio. Not required to carry anything weighing over 20 pounds. Occasionally push/pull doors or desk drawer. Rare push/pull in the process of apprehending a trespasser if the individual is caught and restrained. Perform Work on Ladders Climb Stairs Occasionally may be required to climb stairs up several flights. Twisting Rare twisting will be performed. Stooping / Bending Bending/stooping while patrolling/making checks of the facility. Squatting / Kneeling Rare squatting/crouching will be performed. Crawling Balancing (Left/Right/Both) Reach Waist to Shoulder Occasional reaching between waist and shoulder height when checking doors to ensure they are locked. Work Above Shoulders Rare reaching below waist or overhead. Keyboarding May access and document information using a keyboard. Wrist Flexion/Extension While keyboarding. Based on F Page 3 of 6

195 Claimant: Claim No.: Job Title: Security Guard Body Part Injured: DOT Code: Handle/Grasp Frequently required to handle a radio, grasp doors/door knobs, etc.. Forceful Grasp Frequently required to handle a radio, grasp doors/door knobs, etc.. My use force to restrain an individual. Fine Finger Manipulation May be required to use the keyboard, telephone, radio, etc. Hand Controls Intermittently use hand controls such as push button, dial turn, flipped switch, etc. Intermittent use of hand and foot controls to operate a vehicle as directed by the employer. Foot Controls Intermittently use hand controls such as push button, dial turn, flipped switch, etc. Intermittent use of hand and foot controls to operate a vehicle as directed by the employer. Repetitive Motion Body part: Vibratory Tasks - Low Vibratory Tasks - High Talking Necessary for communicating and taking instruction from others. Hearing Necessary for communicating and taking instruction from others. Tasting/Smelling The sense of smell is needed to assess the odor of smoke/fire. Visual - Near Acuity Necessary for doing the job effectively and correctly. Visual - Far Acuity Necessary for doing the job effectively and correctly. Visual - Depth Perception Necessary for doing the job effectively and correctly. Visual - Color Necessary for doing the job effectively and correctly. Discrimination Visual - Accommodation Necessary for doing the job effectively and correctly. Visual - Field Of Vision Necessary for doing the job effectively and correctly. Environmental Conditions Frequency Activity Description Exposure to Weather May patrol around the exterior of the property. Extreme Cold Extreme Hot Wet and / or Humidity During inclement weather. Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Based on F Page 4 of 6

196 Claimant: Claim No.: Job Title: Security Guard Body Part Injured: DOT Code: Environmental Conditions Frequency Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud Analyst s Comments: Possible Employer Modifications: 3 Activity Description May be exposed to some infectious diseases and cleaning agents. Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

197 Claimant: Claim No.: Job Title: Security Guard Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

198 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Stock Clerk DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Stock Clerk Brief Job Description/Duties: Receive and verify food coming into the facility. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. 50 lbs. 30 lbs. 10 lbs. lbs. Carry lbs. lbs. 30 lbs. 10 lbs. lbs. Push / Pull lbs. lbs. 15 lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC

199 Vocational Firm: Address: th Ct. SW., Building A Olympia, WA Job Analysis Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No.: Job Title: Stock Clerk DOT #: Phone: Involved body parts: Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal Job Title: Stock Clerk DOT Title: Stock Clerk SVP: 4 DOT #: Wage: Type of Industry: 249, Clerical & Kindred Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone: Job Title: Stock Clerk DOT Code: Type of Analysis: On-Site Interview Representative Brief Job Summary: Receive and verify food coming into the facility. Essential Job Functions: Record information for reordering. May be required to rotate stock to ensure timely food use. Store various food in refrigerator or dry storage room. Count and verify incoming food to ensure that the order is correct. Take inventory of available stock and reorder according to facility needs or menu created by dietitian. May be required to sweep and mop storage areas. The worker may be required to assist elsewhere within the facility when not performing stock clerk duties; such as assist in the kitchen, dishwashing or preparing meals. May also contribute to planning the meals with the director of Dietary Services. Most employees are also required to perform other tasks other than stock room work. Training/Preparation Required: Over 3 months up to 6 months. Machine, Tools, Special Equipment, Personal Protective Equipment Used: Hand truck Based on F Page 2 of 6

200 Claimant: Claim No.: Job Title: Stock Clerk Body Part Injured: DOT Code: Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. 5 hrs. 35 min.) Heavy Hours Per Day C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week % Time Sitting Occasional sitting is performed for one to two hours during a work day; intermittent with standing/walking. Standing Occasional to Frequent standing, for three to four hours out of an eight hour work day on primarily linoleum or tile floor surfaces. Walking Occasional to Frequent walking, for three to four hours out of an eight hour work day on primarily linoleum or tile floor surfaces. Job Demand Frequency & Weight Activity Description Lifting Carry (Dist.) 15 ft. Pushing/ Pulling (Dist.) ft lbs. lbs. lbs. of force Frequent lifting of various canned products. Occasional lifting of boxes filled with various food stuffs weighing up to 30 pounds. Seldom lifting of bags of potatoes or other heavy items. No lifting over 50 pounds. A hand truck is available to move heavy items. To move hand truck and to clean work area. Perform Work on Ladders Climb Stairs Climb a step ladder to reach higher shelves in stock room. Twisting Twisting while sweeping and mopping the storage areas or when rotating stock. Stooping / Bending Bending/stooping occurs while taking inventory or stocking food on lower shelves. Squatting / Kneeling Crouching/squatting occurs while taking inventory of food on lower shelves. Intermittent with bending. Crawling Based on F Page 3 of 6

201 Claimant: Claim No.: Job Title: Stock Clerk Body Part Injured: DOT Code: Balancing Maintain balance on the step-ladder. (Left/Right/Both) Reach Waist to Shoulder Reach at and below shoulder height when counting stock. Work Above Shoulders Reach above shoulder height when checking inventory on higher shelves or placing received stock onto upper shelves. Keyboarding May record inventory data using a keyboard. Wrist Flexion/Extension To perform job duties. Handle/Grasp Handle various food items; i.e., boxes and cans of various prepared food substances. Forceful Grasp Grasp canned food items, boxes, pen/pencil, and paper for inventory. Fine Finger Manipulation To record inventory. Hand Controls May operate some basic controls. Foot Controls Repetitive Motion Body part: Arms Reaching and handling. Vibratory Tasks - Low Vibratory Tasks - High Talking Necessary for communicating with others and taking instructions from others. Hearing Necessary for communicating with others and taking instructions from others. Tasting/Smelling Visual - Near Acuity Necessary for counting and ensuring correctiveness of paperwork. Visual - Far Acuity Visual - Depth Perception To perform various job duties. Visual - Color Discrimination To differentiate between different items. Visual - Accommodation Visual - Field Of Vision To navigate facility. Environmental Conditions Frequency Activity Description Exposure to Weather Extreme Cold To store items in walk-in refrigerator. Extreme Hot In oven and dish washing areas of the kitchen. Wet and / or Humidity Kitchen area may be wet. Based on F Page 4 of 6

202 Claimant: Claim No.: Job Title: Stock Clerk Body Part Injured: DOT Code: Environmental Conditions Frequency Proximity to Moving Mechanical Parts Exposure to Explosives Atmospheric Conditions Exposed Heights Exposure to Electricity Exposure to Toxic / Caustic Chemicals Exposure to Radiation Other: Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud Analyst s Comments: Possible Employer Modifications: 3 Activity Description May be exposed to some cleaning solutions. Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a best estimate may have been used. Analyst: 6/26/16 Janet Snyder, B.A., CDMS Date Based on F Page 5 of 6

203 Claimant: Claim No.: Job Title: Stock Clerk Body Part Injured: DOT Code: Medical Provider I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work. State the date worker is released to return to work if different from today s date. I agree the injured worker can perform the described job but only with modifications as described below. Comments: Modifications are needed on a permanent or temporary basis. The above-named injured worker temporarily cannot perform this job based on the following physical limitations: Anticipated release date: Treatment plan: The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations: (State objective medical findings) Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim. Signature Date Print Name Attending Physician Consulting Physician Pain Program Physician IME Physician PCE Therapist OT / PT Therapist Based on F Page 6 of 6

204 Transitional Work Options Department of Labor and Industries Physician Billing Codes 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Worker: Claim No: SUMMARY OF CRITICAL PHYSICAL DEMANDS AND JOB DUTIES: FEEDING PATIENTS: In this transitional option, the employee will assist with placing bibs on patients before meals, serving trays in the dining room and pouring liquids, cutting meat and other foods, pouring coffee, tea and other drinks, feeding patients after they are positioned, recording the input and output charts, returning trays to cart, assist with brushing teeth, and pick up water pitchers and redistribute with ice and water after the kitchen has cleaned the pitchers. Physically this job requires intermittent standing and walking predominately, for two hours at a time up to eight hours out of an eight-hour day. There is intermittent sitting that can be performed while doing charting and while assisting with some feeding activities. Lifting would be up to a maximum of 10 pounds. There would be frequent reaching, grasping, and handling in this position. There would be occasional bending and very rare kneeling or crouching. The majority of reaching would be at waist to chest height, although reaching would be performed at all ranges of motion. There would be some intermittent pushing or pulling of food trays requiring minimal force. PHYSICIAN REVIEW: APPROVE DISSAPPROVE DIRECT PATIENT CARE-PERSONAL HYGIENE ASSISTANCE: This transitional option consists of assisting with washing faces and hands for meals, sorting socks, performing minor mending, shampooing hair, assisting with brushing teeth, trimming finger and toe nails, combing hair, shaving male patients, assisting with putting away clothing, cleaning closets, helping with activities, and delivering water pitchers. The majority of the activities are performed while in a standing and walking position, although there may be intermittent sitting performed while doing mending, sorting socks, or other miscellaneous activities. Lifting would be up to a maximum of 10 pounds, with carrying only necessary for short distances. There would be occasional bending and twisting performed, and rare kneeling or squatting. There would be occasional pushing and pulling consisting of a water cart, with frequent handling, grasping, fingering and reaching at all ranges of motion. PHYSICIAN REVIEW: APPROVE DISAPPROVE NON DIRECT PATIENT CARE ACTIVITIES LEVEL I: This position consists of performing activities such as labeling beds and drawers, folding laundry, dusting, clearing dishes, adjusting bed heights, marking clothing and belongings, organizing drawers, delivering mail, taking vital signs, taking pictures of new admissions, assisting patients with hand work activities, completing flow charts, wiping off the microwave and checking the showers for wash clothes and soap. The majority of these activities are performed while standing and walking, although there may be very intermittent sitting performed. Lifting ranges up to 10 pounds, with carrying performed up to 10 pounds for 50 to 100 feet. There is occasional pushing and pulling, and frequent

205 Claim No: Worker: Job Analysis Transitional Work Options Page 2 handling, and grasping required. There is occasional bending, kneeling or crouching. Reaching is performed at all ranges of motion. PHYSICIAN REVIEW: APPROVE DISAPPROVE NON DIRECT PATIENT CARE ACTIVITIES LEVEL II: These types of activities consist of transporting soiled linen to the holding area, washing walls, washing windows and pictures, cleaning up after meals, cleaning toilet seats, cleaning urine and other accidents from the floor, defrosting and cleaning the refrigerator, assisting with washing the body after death and washing the wheelchairs or shower chairs. These activities require standing and frequent bending, and occasional kneeling, or crouching. There may be frequent pushing and pulling in this position. There is constant reaching at all ranges of motion, and frequent grasping and handling. Lifting ranges up to 25 pounds. PHYSICIAN REVIEW: APPROVE DISAPPROVE OFFICE CLERK: In this transitional position the worker would assist with greeting visitors, answering the telephone, taking messages, performing filing, entering information into the computer, and performing copying as needed. This position is predominately performed in a seated position, although there would also be intermittent standing and walking around the office area. Lifting would be a maximum of 10 pounds. There would be occasional pushing and pulling of desk drawers and file drawers requiring minimal force. There would be rare kneeling, crouching, or bending required in this position. Reaching would be predominately at wait to chest height, with frequent grasping, handling, fingering and feeling. PHYSICIAN REVIEW: APPROVE DISAPPROVE TRANSPORTING PATIENTS AND EQUIPMENT: Push residents in wheelchairs around facility on linoleum floors, push carts with meal trays, push laundry carts around facility. These activities require pushing or pulling with lbs. force, standing & walking, and occasional bending & kneeling or crouching. PHYSICIAN REVIEW: APPROVE DISAPPROVE Work Schedule: Will be variable depending on specific physician recommendations. Physician comments (please document how many hours per day the worker can work and any physical restrictions): Physician Date

206 Department of Labor and Industries Physician Billing Codes Summary included in JA review 1038M Limit one per day 1028M Additional review, up to 5 per worker per day Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the APF grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed. Job Analysis Summary Full Job Analysis (JA) Attached for Reference Job Title: Wait Person DOT Code: Name: Date: Claim Number: Accepted Conditions: Job Title: Wait Person Brief Job Description/Duties: Serves food to customers in an informal dining area. Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal Worker will: Never Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant % Unrestricted Sit Stand Walk Work on ladders Climb Stairs Twist Bend / Stoop Squat / Kneel Crawl Reach Work above shoulders Keyboard Wrist (flexion/extension) Grasp (forceful) Fine manipulation Operate foot controls Vibratory tasks; high impact Vibratory tasks; low impact Lift lbs. lbs lbs lbs. lbs. Carry lbs. lbs lbs lbs. lbs. Push / Pull lbs. lbs. 10 lbs. lbs. lbs. Optional Comments: Approve Yes Yes, with the following modifications: Disapprove If temporarily disapproved, for how long? Medical Provider s Printed Name Medical Provider s Signature Date F Job Analysis Summary Page 1 of 6 Index: VOC