SOP 104.23-att-1: WC-240a Job Analysis Form

SOP 104.23
Attachment 1

10/8/19
WC-240a JOB ANALYSIS
# GEORGIA STATE BOARD OF WORKERS' COMPENSATION

JOB ANALYSIS
Instructions: File this form as an attachment to a WC-240

|Board Claim No.|Col2|Col3|Employee Last Name|Col5|Col6|Col7|Employee First Name|Col9|Col10|Col11|Col12|M.I.|SSN or Board Tracking #|Col15|Col16|Date of Injury|Col18|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|EMPLOYER|Name
|Name
|Name
|Name
|Name
|Name
|Name
|Name
|Contact Person
|Contact Person
|Contact Person
|Contact Person
|Contact Person
|Contact Person
|Contact Person
|Contact Person
|Contact Person
|
|Job Title
|Job Title
|Job Title
|Job Title
|Job Title
|Job Title
|Job Title
|Job Title
|Job Title
|Position
|Position
|Position
|Position
|Position
|Position
|Position
|Position
|Position
|
|Telephone Number
|Telephone Number
|Telephone Number
|Telephone Number
|Telephone Number
|Prepared by:
|Prepared by:
|Prepared by:
|Prepared by:
|Prepared by:
|Prepared by:
|Prepared by:
|Prepared by:
|Prepared by:
|Prepared by:
|Date:
|Date:
|Date:
|
|SCHEDULE|SCHEDULE|SCHEDULE|SCHEDULE|SCHEDULE|SCHEDULE|SCHEDULE|SCHEDULE|SCHEDULE||WORK PACE|WORK PACE|WORK PACE|WORK PACE|WORK PACE|WORK PACE|WORK PACE|WORK PACE|
|Shift(s):
|Shift(s):
|Shift(s):
|Days:
|Days:
|Days:
|Days:
|Days:
|Days:
|Days:
|Self-Paced?

Yes

No|Self-Paced?

Yes

No|Self-Paced?

Yes

No|Incentive Based?

Yes

No|Incentive Based?

Yes

No|Incentive Based?

Yes

No|Machine Paced?

Yes

No|Machine Paced?

Yes

No|
|Hours / Week:
|Hours / Week:
|Hours / Week:
|Overtime:
|Overtime:
|Overtime:
|Rate of Pay:
|Rate of Pay:
|Rate of Pay:
|Rate of Pay:
|Production Standards (Define Requirements):
|Production Standards (Define Requirements):
|Production Standards (Define Requirements):
|Production Standards (Define Requirements):
|Production Standards (Define Requirements):
|Production Standards (Define Requirements):
|Production Standards (Define Requirements):
|Production Standards (Define Requirements):
|
|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|JOB DESCRIPTION (What is the purpose and objective of this job?):


|
|WEIGHT|WEIGHT|FREQUENCY|FREQUENCY|FREQUENCY|FREQUENCY|FREQUENCY|FREQUENCY|FREQUENCY|FREQUENCY|FREQUENCY|OBJECTS|OBJECTS|OBJECTS|Lowest
Point
Lift/Lower|Lowest
Point
Lift/Lower|Lowest
Point
Lift/Lower|Highest
Point
Lift/Lower|
|LIFTING|LIFTING|Never|Never|Occasional
(up to 1/3 of the time)|Occasional
(up to 1/3 of the time)|Frequent
(1/3 to 2/3 of the
time)|Frequent
(1/3 to 2/3 of the
time)|Constant
(over 2/3 of the
time)|Constant
(over 2/3 of the
time)|Constant
(over 2/3 of the
time)|Constant
(over 2/3 of the
time)|Constant
(over 2/3 of the
time)|Constant
(over 2/3 of the
time)|Height|Height|Height|Height|
|Negligible|Negligible|||||||||||||||||
|10 lbs. Max.|10 lbs. Max.|||||||||||||||||
|20 lbs. Max.|20 lbs. Max.|||||||||||||||||
|25 lbs. Max.|25 lbs. Max.|||||||||||||||||
|50 lbs. Max.|50 lbs. Max.|||||||||||||||||
|100 lbs. Max.|100 lbs. Max.|||||||||||||||||
|Over 100 lbs.|Over 100 lbs.|||||||||||||||||
|CARRYING|CARRYING|||||||||||||Max. Distance Carried|Max. Distance Carried|Max. Distance Carried|Max. Distance Carried|
|Negligible|Negligible|||||||||||||||||
|10 lbs. Max.|10 lbs. Max.|||||||||||||||||
|20 lbs. Max.|20 lbs. Max.|||||||||||||||||
|25 lbs. Max.|25 lbs. Max.|||||||||||||||||
|50 lbs. Max.|50 lbs. Max.|||||||||||||||||
|100 lbs. Max.|100 lbs. Max.|||||||||||||||||
|Over 100 lbs.|Over 100 lbs.|||||||||||||||||
|PUSH/PULL
MAX FORCE|PUSH/PULL
MAX FORCE|||||||||||||Max. Distance Moved|Max. Distance Moved|Max. Distance Moved|Max. Distance Moved|
|Negligible|Negligible|||||||||||||||||
|10 lbs. Max.|10 lbs. Max.|||||||||||||||||
|20 lbs. Max.|20 lbs. Max.|||||||||||||||||
|25 lbs. Max.|25 lbs. Max.|||||||||||||||||
|50 lbs. Max.|50 lbs. Max.|||||||||||||||||
|100 lbs. Max.|100 lbs. Max.|||||||||||||||||
|Over 100 lbs.|Over 100 lbs.|||||||||||||||||

IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov

WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. !34-9-18 AND !34-9-19).

Record Retention: Upon completion, this form shall be retained permanently in the employees local medical file.

SOP 104.23
Attachment 1

10/8/19
WC-240a JOB ANALYSIS
# GEORGIA STATE BOARD OF WORKERS' COMPENSATION

|POSTURES /
MOVEMENTS|Col2|MAX. CONSEC. MIN/HOURS|TOTAL DAILY
HOURS|POSITION CHANGE
OPTIONAL?|FURTHER
DESCRIPTION|
|---|---|---|---|---|---|
|Sitting|Sitting|||||
|Standing (in place)|Standing (in place)|||||
|Walking|Walking|||||
|Use Arm/Leg Controls|Use Arm/Leg Controls|||||
||Never|Occasional
(up to 1/3 of the time)|Frequent
(1/3 to 2/3 of the time)|Constant
(over 2/3 of the time)||
|Bending||||||
|Turn/Twisting||||||
|Kneeling||||||
|Squatting||||||
|Crawling||||||
|Climbing||||||
|Reaching (out)||||||
|Reaching (up)||||||
|Wrist Turning||||||
|Grasping||||||
|Pinching||||||
|Finger
Manipulation||||||

LIST EQUIPMENT, MACHINES, TOOLS, VEHICLES USED

SPECIAL CONSIDERATIONS (ENVIRONMENTAL CONDITIONS, VISION, HEARING, HEIGHT)

|TO BE FILLED OUT BY THE AUTHORIZED TREATING PHYSICIAN|Col2|Col3|
|---|---|---|
|1.Employee can perform this job while taking medications as prescribed
Yes
No
2.

I do release the employee to the job described
3.

I do not release the employee to the job described
4.

I only release the employee to the job described with the following restrictions/limitations/modifications:
|1.Employee can perform this job while taking medications as prescribed
Yes
No
2.

I do release the employee to the job described
3.

I do not release the employee to the job described
4.

I only release the employee to the job described with the following restrictions/limitations/modifications:
|1.Employee can perform this job while taking medications as prescribed
Yes
No
2.

I do release the employee to the job described
3.

I do not release the employee to the job described
4.

I only release the employee to the job described with the following restrictions/limitations/modifications:
|
|Physician's Name
|Physician's Signature|Date|

IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov

WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. !34-9-18 AND !34-9-19).

Record Retention: Upon completion, this form shall be retained permanently in the employees local medical file.