Fill and Sign the Analysis of Upper Extremity Use for Office Activities Oregon Form

Analysis of upper extremity use for office activities Worker name:       Claim #:       Job title       Employer:       Equipment/modifications provided/potential modifications:       Work hours/Days per week:       Form completed by (include title):       Job tasks Describe – see instructions on reverse. Minutes at a time Times per day Hours per day Restrictions (For completion by physician) If yes, provide detail below. Keyboarding:                         Yes No Mousing:                         Yes No Handwriting:                         Yes No Gripping:                         Yes No Reaching/handling:                         Yes No 10-Key/Calculator:                         Yes No Lifting/carrying:                         Yes No Filing:                         Yes No Phone/headset:                         Yes No Pushing/pulling:                         Yes No Sorting:                         Yes No Stapling/punching:                         Yes No Other (describe):                         Yes No Physician: Please complete remainder of form. Restrictions:       Worker is released for modified work effective:       (date) Worker is released for regular work effective:       (date) Physician’s signature: X Date: 440-3289 (3/01/DCBS/WCD/WEB) Tips for form completion 1. In the form heading under “Equipment/modification provided/potential modifications,” describe any ergonomic equipment already in place and if the worker’s hours can be modified and tasks reassigned. 2. Under “Job tasks,” provide as much relevant information as possible to ensure the physician receives enough information to determine what the worker is capable of doing. Please consider the following: Keyboarding: Because keyboarding demands differ according to task, include how much time the worker spends on each of the following: e-mail, word processing, data entry, and “other” keyboarding. Mousing: Physical movement differs substantially, depending upon the type of mouse used. Enter the type of device: standard mouse, track ball, mouse pad, etc. Handwriting: Describe handwriting duties in detail. Meeting minutes are more demanding than an occasional signature. Completion of carbonless forms requires greater force than plain-paper forms. Gripping: Say if gripping is narrow or wide, and if it is forceful, sustained, and/or repetitive. Reaching/Handling: Describe reaching requirements, including: length of reach, if the hands carry weight during the reach, if the reach is up to shelving or down into file drawers, etc. 10-Key/Calculator: Say whether the worker uses the computer keyboard for calculations or a different machine/calculator; the force required and reach involved differ substantially. Lifting/Carrying: Enter the weight of the items, the distance of the lift, how the items are carried, and how far they are carried. Filing: Enter the weight of the items being filed, the height of the drawers where the filing is done, whether drawers need to be pulled out, and how much weight is in them. Phone/Headset: Enter the number of phone calls, in and out, on an average day. Say if a headset is always used and, if not, describe the reach required. Pushing/Pulling: Explain what the worker is pulling and/or pushing and whether it is loaded with items or empty, the amount of force required to push or pull, and how much weight is involved. Sorting: Describe the type of sorting, the items being sorted, and if reaching is involved. Stapling/Hole Punching: Describe the tools involved and whether they are manual or electric. Other: Describe any other tasks done by the worker that involve upper extremity use. Include other helpful information, e.g., “the worker telecommutes two days a week.” The home office may need to be addressed, as well. Restrictions: After the employer completes the job task descriptions, the physician will complete the “Restrictions” column and check “yes” next to any job task for which restrictions are necessary, given the worker’s injury and recovery status. In the space provided, the physician should then enter specific restrictions for the job task(s) and complete the remainder of the form. 2