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.
Use the worksheet with the source records
- Enter dates from the notice, medical record, payment record, or message instead of memory.
- Leave an item blank when it is unknown; do not guess to complete the page.
- Keep a private copy and update it after a new notice, appointment, payment, or work-status change.
- Bring the worksheet and the supporting documents to an agency call or lawyer consultation.