R W PROGRAM TRANSITIONAL WORK ASSIGNMENT TO WORK PROGRAM TRANSITIONAL WORK ASSIGNMENT TITLE TWA...

RETURN TO WORK PROGRAM

TRANSITIONAL WORK ASSIGNMENT

TITLE TWA Number

Blank Form Office

Sales Materials 1 Sales Assistant 2 Telephone Assistant 3 File Purge 4 Counting Money 5 New Employee Orientation 6

Observations / Inspections / Quality Assurance Conduct Behavior Safety Observations 7 Conduct Driver Safety Check Ride 8 Conduct Plant Safety Inspection 9 Conduct Periodic Accident Claims Analysis 10 Quality Assurance - Routes 11 Quality Inventory Checker - Warehouse 12

Janitorial (Inside and Outside) Janitorial 13 General Cleaning 14 Warehouse Clean Up 15 Yard Clean up and Check 16 Trailer Cleaner 17 Dock/Apron Cleaner 18 Sit Down Sweeper 19

Maintenance / Warehouse / Production Painter (Helper) 20 Groundskeeper Assistant 21 Modified Forklift Operator 22 Returns: Freezer and Warehouse 23 Food Service Assistant – Cashier Duties 24 Food Service Assistant 25 Security Attendant 26

Rev. 9/22/2010

RETURN TO WORK PROGRAM TRANSITIONAL WORK ASSIGNMENT

Assignment: (Blank Form) Location: Available Hours: Report To: Hours Per Day: ASSIGNMENT DESCRIPTION: COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.

TEMPORARY ASSIGNMENT ACTIVITIES NOTE: On terms of an eight-hour work day: Limited (0-1 hour), Occasionally (1-2 hours) equals 1% to 25%, Frequently (3-

4 hours) equals 26% to 50%, Repeatedly (5-6 hours) equals 51% to 75%, and Continuously (7+ hours) equals 76% to 100% .

Activity Duration Activity Duration

Sustained Postures Repetitive Use of Hands/Wrists Sit: Grasp: Stand: Push/Pull: Walk: Fine Manipulation:

Intermittent Activity Material Handling lbs. Bend: Lift: Kneel/Squat: Carry: Climb Stairs: Push: Crawling: Pull:

Overhead Reach: Miscellaneous

Typing/Keyboard Vehicle Operation: Exposure to Water:

Exposure to Chemicals:

Exposure to Weather:

Special Clothing:

Other accommodations: ______________________________________________________________________________________ ______________________________________________________________________________________



Assignment: Sales Materials Location: Available Hours: 4 - 5 Report To: Hours Per Day: ASSIGNMENT DESCRIPTION: Assignment is to insert promotional materials into sales brochure. Assemble miscellaneous flyers, labels or other lightweight paper items for use by sales staff, merchandisers, etc. Self-paced activity, employee can change positions as needed (sit, stand, etc.). No fine manipulations required, occasional grasp and open to insert materials. COMMENTS: (Captive Member) is flexible with hours and work activities within the employee’s restrictions and capabilities. Assignments can be combined to create up to an eight-hour schedule. Weights and measures are an average based on the work locations and equipment observed during the defined tasks.

TEMPORARY ASSIGNMENT ACTIVITIES

NOTE: On terms of an eight-hour work day: Limited (0-1 hour), Occasionally (1-2 hours) equals 1% to 25%, Frequently (3-4 hours) equals 26% to 50%, Repeatedly (5-6 hours) equals 51% to 75%, and Continuously (7+ hours) equals 76% to 100% .


Sustained Postures Repetitive Use of Hands/Wrists Sit: Frequently Grasp: Occasionally

Stand: Frequently Push/Pull: N/A

Walk: 14 steps to display area, two times per shift.

Limited Fine Manipulation: N/A

Intermittent Activity Material Handling lbs. Bend: Non-repetitive at waist Lift: Promotional Material 0 - 5 Limited Kneel/Squat: N/A Carry: Promotional Material 0 - 5 Limited Climb Stairs: N/A Push: N/A

Crawling: N/A Pull: N/A

Overhead Reach: N/A Miscellaneous

Typing/Keyboard Vehicle Operation: N/A N/A Exposure to Water: N/A

Exposure to Chemicals: N/A

Exposure to Weather: N/A

Special Clothing: N/A

Other accommodations: Can bring materials to work area to eliminate any lifting._ _________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________



Assignment: Sales Assistant Location: Available Hours: 8 Report To: Hours Per Day: ASSIGNMENT DESCRIPTION: Taking orders and working with customers over the telephone. Self-paced activity, employee has the option to take rest breaks as indicated. Employee can sit or stand, use headset if requested. COMMENTS: (Captive Member) is flexible with hours and work activities within the employee’s restrictions and capabilities. Assignments can be combined to create up to an eight-hour schedule. Weights and measures are an average based on the work locations and equipment observed during the defined tasks.




Sustained Postures Repetitive Use of Hands/Wrists Sit: Can alternate with standing Frequently Grasp: Repetitive use of hands with telephone

keypad and computer.

Frequently

Stand: Can alternate with sitting Frequently Push/Pull: N/A

Walk: Very short distances. Occasionally Fine Manipulation: N/A

Intermittent Activity Material Handling lbs. Bend: N/A Lift: Lifting Paperwork 0 - 5 Limited Kneel/Squat: N/A Carry: Lifting Paperwork 0 - 5 Limited

Climb Stairs: N/A Push: N/A



Typing/Keyboard Vehicle Operation: N/A Some computer keying Occasionally Exposure to Water: N/A







Assignment: Telephone Assistant Location: Office Available Hours: 8:00 am – 9:00 am

2:30 pm – 4:30 pm Report To: Hours Per Day: 1 - 2 ASSIGNMENT DESCRIPTION: The tasks associated with this transitional work assignment involve telephone response to customer calls, explain location of customer’s freight, answer and route calls in office. Perform light clerical. (Check computer screen for information). COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: To use phone and reference computer screen

Occasionally Grasp: Phone Occasionally

Stand: As necessary for breaks Limited Push/Pull: N/A Walk: To and from area Limited Fine Manipulation: Select keys, phone, pencil Occasionally

Intermittent Activity Material Handling lbs. Bend: N/A Lift: N/A Kneel/Squat: N/A Carry: N/A Climb Stairs: N/A Push: N/A Crawling: N/A Pull: N/A


Typing/Keyboard Vehicle Operation: N/A Very minimal use of keyboard to change screens

Limited Exposure to Water: N/A

Exposure to Chemicals: N/A Exposure to Weather: N/A Special Clothing: N/A Other accommodations:

______________________________________________________________________________________ ______________________________________________________________________________________


TRANSITIONAL WORK ASSIGNMENT Assignment: File Purge Location: Office Available Hours: 2 – 3 days/month or 3-4

hours/day for several days Report To: Hours Per Day: Flexible ASSIGNMENT DESCRIPTION: The tasks associated with this transitional work assignment involve cleaning file drawers of information and materials that have met retention limits (periods of 6 months to several years). Involves pulling, removing files with old dates and placing in boxes on a table or desk. File cabinet drawers are 12 “ x 54”. Secretary or Manager will scan for accuracy. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: As necessary for breaks or to work in lower drawers

Frequently Grasp: Files, paper, drawer handle Frequently

Stand: As necessary Occasionally Push/Pull: File drawers up to 15 lbs. – 20 lbs. Frequently

Walk: To and from work area Occasionally Fine Manipulation: N/A

Intermittent Activity Material Handling lbs. Bend: Prefer kneel/squat to bending Limited Lift: Files <5 lbs. Occasionally

Kneel/Squat: Limited Carry: Files <5 lbs. Occasionally Climb Stairs: Limited Push: File drawer < 20 lbs. Frequently Crawling: N/A Pull: File drawer < 20 lbs. Frequently

Overhead Reach: Forward Reach Limited Miscellaneous





Other accommodations: Other employees can lift filled file boxes._________________________________ ______________________________________________________________________________________



Assignment: Counting Money Location: Available Hours: 2 Hours Report To: Hours Per Day: ASSIGNMENT DESCRIPTION: Pour money from machines into bags, sort coins, wrap coins and total coin amount. Self-paced activity, employee can modify to meet restrictions. Can sit and take standing or other rest breaks as needed. COMMENTS: (Captive Member) is flexible with hours and work activities within the employee’s restrictions and capabilities. Assignments can be combined to create up to an eight-hour schedule. Weights and measures are an average based on the work locations and equipment observed during the defined tasks.




Sit: Job can be done sitting/standing Occasionally Grasp: Ability to alternate hands Limited

Stand: Position can be performed sitting/standing

Limited Push/Pull: N/A

Walk: Short distances from machine to work area, approximately 50 ft.

Occasionally Fine Manipulation: Coin rolls filled and closed Limited

Intermittent Activity Material Handling lbs. Bend: Limited bending to collect money from machine

Limited Lift: Carry money bags 10 – 30 lbs. Frequently

Kneel/Squat: N/A Carry: Carry money bags 10 – 30 lbs. Frequently

Climb Stairs: N/A Push: Open/close machine doors 1 – 10 lbs. Limited

Crawling: N/A Pull: Open/close machine doors 1 – 10 lbs. Limited






Other accommodations: Can use small cart to transport coin bags if needed._________________________ ______________________________________________________________________________________ ______________________________________________________________________________________


TRANSITIONAL WORK ASSIGNMENT Assignment: New Employee Orientation Location: Available Hours: 1 Report To: Hours Per Day:

ASSIGNMENT DESCRIPTION: Introduce employees to co-workers, take ID photo, and show facility. Employee has the ability to take rest break as needed. COMMENTS: (Captive Member) is flexible with hours and work activities within the employee’s restrictions and capabilities. Assignments can be combined to create up to an eight-hour schedule. Weights and measures are an average based on the work locations and equipment observed during the defined tasks.




Sustained Postures Repetitive Use of Hands/Wrists Sit: Brief discussions Occasionally Grasp: Non-repetitive, very limited use Limited

Stand: Brief, during facility tour Occasionally Push/Pull: N/A

Walk: Tour of facility Occasionally Fine Manipulation: N/A

Intermittent Activity Material Handling lbs. Bend: N/A Lift: Camera, Film, etc. 0 - 5 Limited

Kneel/Squat: N/A Carry: Miscellaneous papers 0 - 5 Limited

Climb Stairs: N/A Push: Opening Doors 0 - 5 Limited

Crawling: N/A Pull: Opening Doors 0 - 5 Limited






Other accommodations: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________________________



Assignment: Conduct Behavior Safety Observations Location: Human Resources Available Hours: 1-2 Report To: Hours Per Day: ASSIGNMENT DESCRIPTION: Walk around production, distribution, and office areas observing other employees performing their jobs. Employee is given a critical task(s) or activity(s) to observe. Walks to area, stands and makes observations of employees performing those pre-selected target activities and/or verify that tasks are being performed in prescribed manner according to standard operating procedures or Job Safety Analyses. Documents all observations on a form. May work alone or as member of team. Can take break as needed. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.



Activity Duration Activity Duration Sustained Postures Repetitive Use of Hands/Wrists

Sit: During task time (1 – 2 Hours) Minimal or as needed.

Grasp: Light grasp on pen/pencil when writing. As needed

Stand: During task time (1 – 2 hours) Continually Push/Pull: N/A Walk: During task time. Frequently or as

needed. Fine Manipulation: Writing Limited

Intermittent Activity Material Handling lbs. Bend: N/A Lift: N/A Kneel/Squat: N/A Carry: Clipboard, if used < l lb. Task time Climb Stairs: No ladder climbing; may need to use stairs to access second floor.

Minimal or as needed.

Push: N/A



Typing/Keyboard Vehicle Operation: N/A N/A Exposure to Water: N/A Exposure to Chemicals: N/A Exposure to Weather: Normal to this facility N/A Special Clothing: Normal for facility Other accommodations:

______________________________________________________________________________________ ______________________________________________________________________________________



Assignment: Conduct Driver Safety Check Ride Location: Human Resources Available Hours: 1-8 Report To: Hours Per Day: ASSIGNMENT DESCRIPTION: Ride as passenger with Route Truck Driver for 1 to 8 hours per day. Conducts driver safety checks; observing driving practices and using a provided checklist. Also makes notations on driver conformance to safe driving practices. Reports to Fleet Manager. Can also do PACE Driver Evaluation rides if trained on PACE concepts. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: During task time – as passenger; wear seat belt

As needed or up to 8 hours

Grasp: Light grasp on pen/pencil when writing. As needed

Stand: During task time Minimal to none Push/Pull: N/A Walk: During task time Minimal to none Fine Manipulation: Writing Limited

Intermittent Activity Material Handling lbs. Bend: Limited to none Lift: None <5 lbs. Limited Kneel/Squat: None Carry: <2 lbs. Minimal Climb Stairs: Must get in/out of vehicle Minimal; as

needed Push: N/A None

Crawling: N/A Pull: N/A None


Typing/Keyboard Vehicle Operation: (passenger only) N/A Exposure to Water: N/A Exposure to Chemicals: N/A Exposure to Weather: Air conditioned cab Minimal Special Clothing: Normal N/A




Assignment: Conduct Plant Safety Inspection Location: Human Resources Available Hours: 1-2 Report To: Hours Per Day: ASSIGNMENT DESCRIPTION: Walk around production, warehouse/distribution and office areas on the lookout for unsafe conditions or other types of physical hazards. May work alone or as a member of a team. Document hazards on form. Can sit/take break as needed. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: During Task Time Minimal to None Grasp: Light grasp on pen/pencil when writing As needed Stand: During Task Time Occasionally Push/Pull: None

Walk: During Task Time Occasionally Fine Manipulation: Writing Limited

Intermittent Activity Material Handling lbs. Bend: Limited to None Lift: No None Kneel/Squat: None Carry: Clipboard, if used <1 lb. Minimal Climb Stairs: Minimal as

needed Push: N/A

Crawling: None Pull: N/A

Overhead Reach: None Miscellaneous

Typing/Keyboard Vehicle Operation: N/A N/A Exposure to Water: N/A Exposure to Chemicals: N/A Exposure to Weather: N/A Special Clothing: N/A



TRANSITIONAL WORK ASSIGNMENT Assignment: Conduct Periodic Accident Claims Analysis Location: Human Resources Available Hours: 1 - 4 Report To: Hours Per Day: ASSIGNMENT DESCRIPTION: Summarize accident data into prescribed categories for meaningful analysis. The extent of analysis will be partly determined on employee’s computer skills and knowledge of software programs such as Excel; otherwise, limited to data gathering and tabular summarization. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: During task time Frequently Grasp: Light grasp on pen/pencil when writing As needed Stand: During task time As needed Push/Pull: N/A

Walk: During task time As needed Fine Manipulation: Writing, keyboard input Minimal

Intermittent Activity Material Handling lbs. Bend: N/A Lift: N/A Kneel/Squat: N/A Carry: N/A




Typing/Keyboard Vehicle Operation: N/A Can type or write Limited N/A

N/A

N/A





Assignment: Quality Assurance Location: Available Hours: 8 - 10 Report To: Hours Per Day: ASSIGNMENT DESCRIPTION: Ride with driver; talk with each customer that is on that route. Get feedback from customer about service and operation times. This is slow-paced activity and a lumbar support can be provided when riding in truck. Fill out feedback report if requested. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: Repeatedly Grasp: Must be able to write documentation. Limited

Stand: Frequently Push/Pull: Must be able to pull partial body weight up to climb into cab.

Frequently

Walk: Occasionally Fine Manipulation: N/A

Intermittent Activity Material Handling lbs. Bend: Very Limited bending, only when getting in/out of cab.

Very Limited Lift: Clipboard with notes 0 – 5 lbs. Frequently

Kneel/Squat: N/A Carry: Clipboard with notes 0 – 5 lbs. Frequently

Climb Stairs: Must climb three steps Push: N/A

Crawling: N/A Pull: Must be able to pull partial body weight up to climb into cab.

Frequently









Assignment: Quality Inventory Checker - Warehouse Location: Warehouse Available Hours: 1st Shift Report To: Warehouse Manager Hours Per Day: 1-8 ASSIGNMENT DESCRIPTION: The tasks associated with this temporary transitional assignment involve general documentation of expiration dates on products stored in the warehouse. Using a pencil the expiration dates of all products are listed on the product expiration forms. The paperwork required is form filling, fine manipulation or writing skill is not necessary. This task is flexible to either stand or sit while documenting and breaks can be taken as needed. Note: Other warehouse personnel are present and able to assist with moving products upon request. Climbing or lifting products can be accomodated if not within the individuals physical restrictions. COMMENTS: Captive Member can be flexible with hours and work within the injured employee’s restrictions and limitations. If on occasion there is any lifting of over 25 lbs. there are other staff near the area that can assist as needed.

TEMPORARY ASSIGNMENT ACTIVITIES NOTE: On terms of an eight-hour work day: Limited (0-1 hour), Occasionally (1-2 hours) equals 1% to 25%, Frequently (3-4

hours) equals 26% to 50%, Repeatedly (5-6 hours) equals 51% to 75%, and Continuously (7+ hours) equals 76% to 100% .


Sit: as desired Frequently Grasp: papers, pens, clipboard Occasionally/ Repeatedly

Stand: as desired Frequently Push/Pull: NA Walk: to and from product areas Limited Fine Manipulation: NA

Intermittent Activity Material Handling lbs. Bend: Limited Lift: papers < 2 Limited/ Frequently Kneel/Squat: Limited Carry: NA Climb Stairs: Limited Push: NA Crawling: NA Pull: NA

Overhead Reach: Limited Miscellaneous

Typing/Keyboard Vehicle Operation: NA keyboard and mouse use N/A Exposure to Water: NA Exposure to Chemicals: NA Exposure to Weather: NA Special Clothing: NA



TRANSITIONAL WORK ASSIGNMENT Assignment: Janitorial Location: Available Hours: 1-2 Report To: Hours Per Day: ASSIGNMENT DESCRIPTION: Employee can sweep using push or standard broom, pick up trash (0 – 5 lbs) and throw garbage away daily into dumpster. Self-paced, employee permitted to break as necessary. Employee can use trash grabber to pick up paper trash. COMMENTS: (Captive Member) is flexible with hours and work activities within the employee’s restrictions and capabilities. Assignments can be combined to create up to an eight-hour schedule. Weights and measures are an average based on the work locations and equipment observed during the defined tasks.




Sustained Postures Repetitive Use of Hands/Wrists Sit: Occasionally Grasp: Use of arm/hands needed to pick up

and place trash in dumpster. Occasionally

Stand: Occasionally Push/Pull: Broom Occasionally


Intermittent Activity Material Handling lbs. Bend: Limited to picking up trash containers. Limited Lift: This can be modified as

needed. Employee has option to lighten load.

1 – 10 lbs. Limited

Kneel/Squat: N/A Carry: This can be modified as needed. Employee has option to lighten load.


Climb Stairs: Occasionally Occasionally Push: Broom if able 0 – 5 lbs. Limited

Crawling: N/A Pull: N/A N/A





Special Clothing: Gloves recommended Occasionally



TRANSITIONAL WORK ASSIGNMENT Assignment: General Cleaning Location: Available Hours: 1 - 5 Report To: Hours Per Day: ASSIGNMENT DESCRIPTION: Includes mopping, sweeping and other general cleaning. Self-paced task, rest breaks can be taken as needed. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: Occasionally Grasp: Can alternate hands Frequently Stand: Frequently Push/Pull: Occasionally Walk: Short distances within a given area Frequently Fine Manipulation: N/A

Intermittent Activity Material Handling lbs. Bend: Required limited bending at waist and knees

Limited Lift: The heaviest item listed is a mop with water. A smaller mop can be substituted.


Kneel/Squat: Limited Carry: Mop, Water 1 – 25 lbs. Limited

Climb Stairs: N/A Push: Pushing mop or broom, wiping down eating area.

1 – 25 lbs. Occasionally






Special Clothing: Gloves recommended Occasionally




Assignment: Warehouse Clean-up Location: Available Hours: 1 - 3 Report To: Hours Per Day: ASSIGNMENT DESCRIPTION: Requires the ability to operate a walkie; picks up boxes, plastics and broken boards from the aisles and pallets. Task can be modified if necessary. Self-paced activity, rest breaks can be given if needed. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: During breaks and rest periods. Very Limited Grasp: Can be done altering left/right hands Occasionally

Stand: Up to 50% of shift, riding the walkie from one aisle to another.

Occasionally Push/Pull: Only to push boxed plastics into dumpster.

Very Limited


Intermittent Activity Material Handling lbs. Bend: Be able to bend knees to pick up items off the floor.

Limited Lift: Clean-up includes picking up boxes, plastics and pallets.


Kneel/Squat: Carry: Clean-up includes picking up boxes, plastics and pallets.


Climb Stairs: Must step up onto and off walkie.

Limited Push: Very limited, only to push boxed plastics into dumpster.


Crawling: N/A Pull:


Typing/Keyboard Vehicle Operation: Walkie Pallet Jack Occasionally N/A Exposure to Water: N/A Exposure to Chemicals: N/A






Assignment: Yard Clean up and Check Location: Yard Available Hours: 1-2 Report To: Hours Per Day: ASSIGNMENT DESCRIPTION: The tasks associated with this transitional work assignment involve walking around the yard during early and late daylight hours, checking fence for holes and yard for debris. Pick up debris, papers, etc., as necessary and report to supervisor any problems or security issues or lighting malfunctions. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: N/A Grasp: Grabber and bag to pick up debris Occasionally Stand: N/A Push/Pull: N/A Walk: Walking around yard Limited Fine Manipulation: N/A

Intermittent Activity Material Handling lbs. Bend: prefer kneel/squat to bending Limited Lift: bag of debris <10 lbs. Occasionally

Kneel/Squat: kneel or squat to pick up debris Limited Carry: bag of debris < 10 lbs. Occasionally Climb Stairs: N/A Push: N/A Crawling: N/A Pull: N/A


Typing/Keyboard Vehicle Operation: N/A N/A Exposure to Water: N/A Exposure to Chemicals: N/A Exposure to Weather: Occasionally Special Clothing: Gloves recommended Occasionally

Other accommodations: Can use trash grabber to reduce bending and grasping.________________________ ________________________________________________________________________________________ ________________________________________________________________________________________


TRANSITIONAL WORK ASSIGNMENT Assignment: Trailer Cleaner Location: Dock Available Hours: Day or Night Shift Report To: Hours Per Day: ASSIGNMENT DESCRIPTION: The task associated with this transitional work assignment involves sweeping out trailers before loading and after unloading, as necessary. Use shovel or a dust pan, sweep debris into shovel or dust pan and empty into waste bins on dock bay. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: N/A Grasp: broom, shovel Frequently

Stand: Waiting for Trailer Limited Push/Pull: broom, shovel Frequently Walk: While cleaning Frequently Fine Manipulation: N/A

Intermittent Activity Material Handling lbs. Bend: Limited Lift: shovel, broom 0 – 15 lbs. Occasionally Kneel/Squat: To pick up dust pan Occasionally Carry: to/from trailer 0 – 15 lbs. Occasionally Climb Stairs: N/A Push: broom 10 – 15 lbs. Frequently

Crawling: N/A Pull: broom 10 – 15 lbs. Frequently


Typing/Keyboard Vehicle Operation: N/A N/A Exposure to Water: N/A Exposure to Chemicals: Limited Exposure to Weather: Limited Special Clothing: Gloves recommended Occasionally



TRANSITIONAL WORK ASSIGNMENT Assignment: Dock/Apron Cleaner Location: Dock Available Hours: Days and Nights Report To: Hours Per Day: 2 to 6 ASSIGNMENT DESCRIPTION: The tasks associated with this transitional work assignment involve sweeping and raking debris that accumulates on dock and on ground below the dock (apron) within several feet of the dock, uses dust pan or shovel to lift debris and place in trash barrel. Occasional bending to pick up dust pan. Requires walking up and down a ramp from 4-1/2 inches to ground level. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: As needed for breaks Limited Grasp: Broom, dust pan, rake Repeatedly Stand: Occasionally Push/Pull: Broom, rake Repeatedly Walk: Repeatedly Fine Manipulation: N/A

Intermittent Activity Material Handling lbs. Bend: Limited Lift: 5 – 6 lbs. Frequently Kneel/Squat: Crouch to use dust pan Limited Carry: Debris to trash < 10 lbs. Frequently

Climb Stairs/Ladder: N/A Push: Broom/rake 10 lbs. Frequently

Crawling: N/A Pull: Broom/rake 10 lbs. Frequently


Typing/Keyboard Vehicle Operation: N/A N/A Exposure to Water: N/A Exposure to Chemicals: N/A Exposure to Weather: Open air by dock Frequently Special Clothing: Gloves recommended N/A Other accommodations:

______________________________________________________________________________________ ______________________________________________________________________________________


TRANSITIONAL WORK ASSIGNMENT Assignment: Sit Down Sweeper Location: Available Hours: 4:00 PM – 5:00 PM Report To: Hours Per Day: 1- 2 ASSIGNMENT DESCRIPTION: This task associated with this transitional work assignment involves operating a sit-down sweeper through the warehouse. Training will be provided to ensure safe operation of the sweeper. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: (1 Hour usually) Occasionally Grasp: Must utilize arm/hand to turn steering

wheel. Limited

Stand: Limited Push/Pull: N/A Walk: Limited Fine Manipulation: N/A

Intermittent Activity Material Handling lbs. Bend: N/A Lift: N/A Kneel/Squat: N/A Carry: N/A Climb Stairs: N/A Push: 0 – 5 lbs. to turn

steering on sweeper 0 – 5 lbs. Limited









TRANSITIONAL WORK ASSIGNMENT Assignment: Painter (Helper) Location: Dock, Office, Yard Available Hours: Day Shift Report To: Hours Per Day: 2 -3 hours, 3 day/month ASSIGNMENT DESCRIPTION: The tasks associated with this transitional work assignment involve painting lines on dock areas, parking spaces, bollards (safety poles) or other areas of the facility; grasping, reaching, use of dominant upper extremity. Roller-chair can be provided for employee to sit in as he/she paints lines and low objects. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: Sit in roller chair as necessary – alternate with standing.

Occasionally Grasp: Chair 2 -5 lbs. Occasionally

Stand: Stand as necessary Occasionally Push/Pull: Chair 2 – 5 lbs. Limited Walk: Walk to and from dock or building Limited Fine Manipulation: N/A

Intermittent Activity Material Handling lbs. Bend: Prefer kneel/squat to bending Limited Lift: Paint can or container 1 – 10 lbs. Occasionally

Kneel/Squat: to pick up debris N/A Carry: Paint can or container 1 – 10 lbs. Occasionally

Climb Stairs: Possibly a few to office N/A Push: Stool/chair on wheels 2 – 5 lbs. Occasionally

Crawling: N/A Pull: Stool/chair on wheels 2 – 5 lbs. Occasionally

Overhead Reach: Possibly on rare occasion Occasionally Miscellaneous

Typing/Keyboard Vehicle Operation: N/A N/A Exposure to Water: Clean up Limited Exposure to Chemicals: Paint Occasionally Exposure to Weather: Possible open air dock Occasionally Special Clothing/Equipment: Paint brush Occasionally Other accommodations:

______________________________________________________________________________________ ______________________________________________________________________________________


TRANSITIONAL WORK ASSIGNMENT Assignment: Groundskeeper Assistant Location: Maintenance Available Hours: Day Shift - Spring,

Summer, Early Fall Report To: Hours Per Day: 1 – 2 hrs/week ASSIGNMENT DESCRIPTION: The tasks associated with this transitional work assignment involve sweeping walkways, watering plants on grounds. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: N/A Grasp: Broom/rake/hose Limited Stand: For breaks Limited Push/Pull: Broom/rake Occasionally

Walk: While sweeping/watering Limited Fine Manipulation: N/A

Intermittent Activity Material Handling lbs. Bend: Prefer kneel/squat to bending Limited Lift: Broom/hose < 10 lbs. Limited Kneel/Squat: To pick up debris Limited Carry: Broom/hose < 10 lbs. Limited

Climb Stairs/Ladder: Possibly a few to office Limited Push: Broom/hose < 10 lbs. Limited

Crawling: N/A Pull: Broom/hose < 10 lbs. Limited


Typing/Keyboard Vehicle Operation: N/A N/A Exposure to Water: From garden hose Occasionally Exposure to Chemicals: N/A Exposure to Weather: Outdoors Occasionally Special Clothing: N/A




Assignment: Modified Forklift Operator Location: Dock Available Hours: All Shifts Report To: Hours Per Day: 2 to 5 ASSIGNMENT DESCRIPTION: The tasks associated with this transitional work assignment involve using a forklift. No lifting of product is involved. Employee uses 3-point contact to climb onto forklift (20 in. step). Requires sitting on padded seat, using foot pedals and hand levers that are power assist and require 15 in. forward/backward motion and approximately 5 lb. – 6 lb. pressure. Left hand brake takes approximately 15 lb. – 25 lb. pressure. Breaks can be taken hourly or less frequently. Steering wheel at waist level in almost horizontal position requires approximately 15 lbs. push/pull. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.


NOTE: On terms of an eight-hour work day: Limited (0-1 hour), Occasionally (1-2 hours) equals 1% to 25%, Frequently (3-



Sustained Postures Repetitive Use of Hands/Wrists Sit: padded seat Repeatedly Grasp: Wheel, levers Repeatedly Stand: for break Limited Push/Pull: Repeatedly levers and wheel Repeatedly

Walk: to and from lift Limited Fine Manipulation: N/A

Intermittent Activity Material Handling lbs. Bend: Prefer kneel/squat to bending Limited Lift: N/A

Kneel/Squat: N/A Carry: N/A Climb Stairs/Ladder: One step into forklift Limited Push: Foot pedals 5 – 25 lbs. Frequently

Crawling: N/A Pull: Hand levers 5 – 25 lbs. Frequently


Typing/Keyboard Vehicle Operation: Forklift Continuously N/A Exposure to Water: N/A Exposure to Chemicals: N/A Exposure to Weather: Roofed open air dock Continuously Special Clothing: N/A Other accommodations:

______________________________________________________________________________________ ______________________________________________________________________________________



Assignment: Returns: Freezer and Warehouse Location: Available Hours: 2-4 Report To: Hours Per Day: 8:00 AM – 12:00 Noon ASSIGNMENT DESCRIPTION: This task involves removing stock from trucks and restocking. Merchandise that comes back on trucks must be placed back in slots. Self-paced activity. May take rest breaks as indicated. Requires lifting, possible use of pallet jack or cart to transport goods. COMMENTS: (Captive Member) is flexible with hours and work activities within the employee’s restrictions and capabilities. Assignments can be combined to create up to an eight-hour schedule. Weights and measures are an average based on the work locations and equipment observed during the defined tasks.




Sustained Postures Repetitive Use of Hands/Wrists Sit: Limited Grasp: Must utilize both hands with this task. Frequently

Stand: Continuously Push/Pull: May use cart Limited

Walk: Limited Fine Manipulation: N/A

Intermittent Activity Material Handling lbs. Bend: Very Limited Lift: Can be modified based upon

lifting restrictions. 0 – 50 lbs. Limited

Kneel/Squat: N/A Carry: Can be modified based upon lifting restriction.

0 – 50 lbs. Frequently

Climb Stairs: Not required. Can use pallet jack for higher to reach racks.

N/A Push: To push some merchandise to back of rack.


Crawling: N/A Pull: To push some merchandise to back of rack.







Other accommodations:

______________________________________________________________________________________ ______________________________________________________________________________________



Assignment: Food Service Assistant - Cashier Duties Location: Cafeteria Available Hours: First Shift Report To: Cafeteria Manager Hours Per Day: 1 – 4 (Part Time) ASSIGNMENT DESCRIPTION: The tasks associated with this temporary transitional assignment involve primarily working as a cashier in the cafeteria. Employee would be required to look at the items the customer would like to purchase and key the items into the cash register, collect the money and make change as needed. Repetitive motion such as scanning items is not required. The employee can sit on a stool while ringing up the orders. Employee would be required to walk from the parking lot to the cafeteria and to and from breaks. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: Mainly or as desired Frequently Grasp: Handle money Frequently Stand: As Desired Limited Push/Pull: Walk: To and from work areas and on breaks Limited Fine Manipulation:

Intermittent Activity Material Handling lbs. Bend: N/A Lift: Money <1 N/A Kneel/Squat: N/A Carry: N/A











Assignment: Food Service Assistant Location: Cafeteria Available Hours: 2nd Shift Report To: Cafeteria Manager Hours Per Day: 1-8 ASSIGNMENT DESCRIPTION: The tasks associated with this temporary transitional assignment involve primarily working in the deli station and preparing approximately 10 sandwiches between 2pm and 6pm employee may sit on a stool or stand. Additional housekeeping duties are to clean and stock the service area as needed, tidy and stock the restrooms, and assist the cook with drying large pots and pans while sitting on a stool or standing,. COMMENTS: (Captive Member) can be flexible with hours and work within the injured team member’s restrictions and limitations. Assignments can be combined to create an eight hour schedule. Weights and measures are an average of sites and equipment observed.

TEMPORARY ASSIGNMENT ACTIVITIES NOTE: On terms of an eight-hour work day: Limited (0-1 hour), Occasionally (1-2 hours) equals 1% to 25%, Frequently (3-4 hours) equals 26% to 50%, Repeatedly (5-6 hours) equals 51% to 75%, and Continuously (7+ hours) equals 76% to 100% .


Sit: mainly or as desired Frequently Grasp: sandwich items, supplies Frequently Stand: as desired Occasionally Push/Pull: NA Walk: to and from work areas and on breaks Limited Fine Manipulation: NA

Intermittent Activity Material Handling lbs. Bend: NA Lift: supplies < 15 Limited Kneel/Squat: NA Carry: papers <15 Limited Climb Stairs: NA Push: NA Crawling: NA Pull: NA

Overhead Reach: NA Miscellaneous

Typing/Keyboard Vehicle Operation: NA N/A Exposure to Water: NA Exposure to Chemicals: Cleaning supplies Exposure to Weather: NA

Special Clothing: NA

Other accommodations: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________



Assignment: Security Attendant Location: Security Office Available Hours: 1st Shift Report To: Area Supervisor Hours Per Day: 1-8 ASSIGNMENT DESCRIPTION: The tasks associated with this temporary transitional assignment involve primarily sitting in the security office area and operating the security gate, monitoring surveillance cameras and monitoring the company fuel tanks. Administrative duties are also performed such as issuing vehicle keys, checking paperwork for out of date products, separating route cards for driver’s daily assignments, and completing reports. COMMENTS: Captive Member can be flexible with hours and work within the injured employee’s restrictions and limitations. If on occasion there is any lifting of over 25 lbs. there are other staff near the area that can assist as needed.




Sustained Postures Repetitive Use of Hands/Wrists Sit: mainly Repeatedly Grasp: papers, pens, files Frequently

Stand: as desired Limited Push/Pull: NA Walk: to and from work areas and on breaks Limited Fine Manipulation: NA

Intermittent Activity Material Handling lbs. Bend: Limited Lift: papers < 2 Frequently Kneel/Squat: NA Carry: papers <1 Minimal Climb Stairs: NA Push: NA Crawling: NA Pull: NA

Overhead Reach: NA Miscellaneous

Typing/Keyboard Vehicle Operation: NA N/A Exposure to Water: NA Exposure to Chemicals: NA Exposure to Weather: NA Special Clothing: NA

Other accommodations: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________________________

R W PROGRAM TRANSITIONAL WORK ASSIGNMENT TO WORK PROGRAM TRANSITIONAL WORK ASSIGNMENT TITLE TWA...

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