SOP_NUMBER: 104.23-att-1
TITLE: WC-240a Job Analysis Form
REFERENCE_CODE: IVO04-0003
DIVISION: Administrative & Finance
TOPIC_AREA: 104 Policy-HR Programs/Support/Assistance
EFFECTIVE_DATE: 2019-10-08
WORD_COUNT: 1081
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/203842
URL: https://gps.press/sop-data/104.23-att-1/
SUMMARY:
This is a job analysis form attachment (WC-240a) used by the Georgia Department of Corrections to document detailed information about an employee's job duties, physical demands, work schedule, and environmental conditions in connection with workers' compensation claims. The form captures job-specific information including lifting/carrying capacity, postures and movements required, equipment used, and medical clearance for job performance. It must be retained permanently in the employee's local medical file.
KEY_TOPICS: job analysis, workers' compensation, WC-240a form, job duties, physical demands, lifting capacity, carrying capacity, postures, movements, work schedule, environmental conditions, medical clearance, employee injury, work restrictions, job description
ATTACHMENTS:
1. WC-240a Job Analysis Form
URL: https://gps.press/sop-data/104.23-att-1/
2. Activity Analysis Form
URL: https://gps.press/sop-data/104.23-att-2/
3. Transitional Employment Plan
URL: https://gps.press/sop-data/104.23-att-3/
4. Transitional Employment Tracking Form
URL: https://gps.press/sop-data/104.23-att-4/
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FULL TEXT:
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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.**