Fill and Sign the Transitional Alternative Duty a Workers Compensation Tool Form

LAB 500 NH WORKERS’ COMPENSATION TASK ANALYSIS In compliance with RSA 281-A:23-b, the employer with 5 or more employees must provide temporary alternative/transitional work opportunities to all employees temporarily disabled by a work-related injury or illness. Task is defined as one of the distinct activities that constitute logical and necessary steps in the performance of a job. A task analysis , for the purpose of this section, is the evaluation of the physical requirements of each task of a particular job or work assignment. Employer Employee Telephone # W.C. Insurer EmployerAddress Complete the following information to describe the employee’s job at the time of injury: Job Title Usual Job? Yes No General Description/Purpose Department Supervisor Description of Tasks (use additional page as needed): 1 . 2 . 3. 4 . 5 . Tools& Equipment Describe Special Demands PHYSICAL DEMANDS Complete the following to show the maximum physical demand for all of the tasks listed above. For example, if Tasks 1 through 4 require no bending but Task #5 requires “occasional” bending, the overall job must be rated as requiring occasional bending. JOB REQUIRES: JOB REQUIRES part of day Continuous 100%-67% Frequent 66%-34% Occasional 33%-1% bending kneeling squatting climbing standing walking sitting reaching driving fine motor skills maximum lifting/carrying of lbs frequent lifting/carry of lbs WORK SCHEDULE: Number of hours/day Number of days/week Does job require Repetitive Motions? (check if applicable) wrist elbow shoulder ankle Right Left ATTACH JOB DESCRIPTION IF AVAILABLE Completed by Title Date 23-b WC (9/2015)