Fill and Sign the Employee Compensation Form

                                                           Left State of CaliforniaDivision of Workers' Compensation DESCRIPTION OF EMPLOYEE'S JOB DUTIES INSTRUCTIONS: This form shall be developed jointly by the employer and employee and is intended to describe the employee's job duties. The completed form will be reviewed by the treating doctor to determine whether the employee is able to return to his/ her job. This is an important document and should accurately show the requirements of the employee's job. If the employee needs help in completing this form, the employee may contact the Information and Assistance Officer at the Division of Workers' Compensation. The phone number can be found in the State Government section of the phone book. EMPLOYEE NAME: (LAST) (FIRST) (M.I.) CLAIM #- EMPLOYER NAME: JOB ADDRESS: JOB TITLE: HRS. WORKED PER DAY: HRS. WORKED PER WEEK: DESCRIPTION OF JOB RESPONSIBILITIES: (DESCRIBE ALL JOB DUTIES) 1. Check the frequency of activity required of the employee to perform the job. ACTIVITY NEVER OCCASIONALLY FREQUENTLY CONSTANTLY (Hours per day) 0 hours up to 3 hours 3-6 hours 6-8+ hours Sitting Walking Standing Bending (neck) Bending (waist) Squatting Climbing Kneelin gCrawling Twisting (neck) Twisting (waist) Hand Use: Dominant hand Right Is repetitive use of hand required?Simple Grasping (right hand) Simple Grasping (left hand) Power Grasping (right hand)Power Grasping (left hand)Fine Manipulation (right hand)Fine Manipulation (left hand)Pushing & Pulling (right hand)Pushing & Pulling (left hand)Reaching (above shoulder level) Reaching (below shoulder level) DWC Form RU-91 (1/95)                                                                        Describe the heaviest item required to carry and the distance to be carried:                                                                                                                                     2. Please indicate the daily Lifting and Carrying requirements of the job: Indicate the height the object is lifted from floor, table or overhead location and the distance the object is carried. LIFTING CARRYINGNever Occasionally Frequently Constantly Height Never Occasionally Frequently Constantly Distance 0 hours up to 3 hours 3-6 hours 6-8+ hours 0 hours up to 3 hours 3-6 hours 6-8+ hours 0-10 lbs. 11 25 lbs. 26-50 lbs. 51-75 lbs.76-100 lbs. 100+ lbs. 3. Please indicate if your job requires: YES NO (IF YES, PLEASE BRIEFLY DESCRIBE) a. Driving cars, trucks, forklifts and other equipment? b. Working around equipment and machinery? c. Walking on uneven ground? d. Exposure to excessive noise? e. Exposure to extremes in temperature, humidity or wetness? f. Exposure to dust, gas, fumes, or chemicals? g. Working at heights? h. Operation of foot controls or repetitive foot movement? i. Use of special visual or auditory protective equipment? j. Working with bio-hazards such as: bloodborne pathogens, sewage, hospital waste, etc. Employee Comments: Employer Comments: EMPLOYER CONTACT NAME: EMPLOYER CONTACT TITLE: EMPLOYER REPRESENTATIVE SIGNATURE: DATE: EMPLOYEE'S SIGNATURE: DATE: QUALIFIED REHAB. REPRESENTATIVE SIGNATURE: (IF APPLICABLE) DATE: DWC Form RU-91 (1/95) Rehabilitation Unit California Division of Workers' Compensation Form RU-91 DESCRIPTION OF EMPLOYEE'S JOB DUTIES Purpose: To obtain a job description which is to be forwarded to the employee's treating physician when an injury or illness results in disability exceeding 90 days. Submitted by: 1. Qualified Rehabilitation Representative, if the injury is before 1/1/94. 2. Claims Administrator if the injury is on or after 1/1/94. When prepared: If the injury is before 1/1/94 the QRR meets with the employee to jointly complete this form and provides a copy of the form in conjunction with the RU-90 to the employee's treating physician. If the injury is on or after 1/1/94, the claims administra- tor consults with the injured worker in completing the RU-90 and then submits it to the treating physician. When submitted: To the treating physician. Do not file the RU-90 or RU-91 with the Rehabilitation Unit unless specifically requested or when submitting information as part of a dispute. Form completion: Qualified Rehabilitation Representative or claims administrator, in consultation with the employee and employer, completes the entire form. Accompanying document: The RU-91 is to be attached to the RU-90 and submitted to the treating doctor. Rehabilitation Unit action: None.