Use this as a private worksheet
Put real job tasks beside current medical restrictions. This is not an official agency or court form.
Job tasks
- ☐ Task: ______________________________
- ☐ Frequency: ______________________________
- ☐ Weight/force: ______________________________
- ☐ Posture/reach: ______________________________
- ☐ Driving/machinery: ______________________________
- ☐ Safety issue: ______________________________
Medical limits
- ☐ Restriction: ______________________________
- ☐ Date issued: ______________________________
- ☐ Provider: ______________________________
- ☐ Duration: ______________________________
- ☐ Task affected: ______________________________
Privacy reminder
Keep sensitive medical, wage, claim-number, and employment information private. Share it only with appropriate official agencies, licensed professionals, insurers, treating providers, or other people who legitimately need it for the claim.