Group Retrospective Rating Program Job Analyses Bank · Group Retrospective Rating Program Job...

Group Retrospective Rating Program

Job Analyses Bank Updated June 2016

Provided in Conjunction with our Group Retro Program Claims Administrator

Phone: (425) 252-7623 www.compriskmgt.com

An Association of Not-For-Profit and Mission Focused Senior Living & Care Providers 1495 Wilmington Drive, Suite 340 | DuPont, WA 98327 | 253-964-8870 | 253-964-8876 Fax | www.LeadingAgeWA.org

Job Analyses Bank Updated June 2016

Table of Contents (Book is in order of job title as listed below)

Assistant Site Manager

Cashier

Community Site Manager

Cook/Helper

Daycare Worker

Dietary Cook

Dishwasher

Driver

Feeder/Bedmaker

Home Care Specialist

Homemaker

Housekeeper – Assisted Living

Housekeeper – Nursing Home

Housekeeper – Retirement Community

Kitchen Aid

Laundry Worker – Nursing Home

Licensed Practical Nurse (LPN) - Wellness Nurse – Assisted Living

Licensed Practical Nurse (LPN) – Primary Care – Nursing Home

Maintenance

Medical Records Clerk

Nurse Assistant Certified (NAC) - Nursing Home

Nurse Manager

Nurses Aid Certified (NAC) – Assisted Living

Physical Therapy Assistant

Receptionist

Recreation/Activities/Therapy Assistant

Registered Nurse (RN) - Wellness Nurse - Assisted Living

Registered Nurse (RN) - Primary Care – Nursing Home

Residential Service Associate (RSA) - Assisted Living

Security Guard

Stock Clerk

Transitional Work Options

Wait Person

Department of Labor and Industries Job Analysis SummaryPhysician Billing Codes Full Job Analysis (JA) Attached for Reference Summary included in JA review 1038M – Limit one per day 1028M – Additional review, up to 5 per worker per day

Vocational Providers: This form is the first page of your JA and serves as a summary and provider signature. Fill out the “APF” grid to reflect the physical demands as documented in the JA. Use the Optional Comments section to reflect other demands not listed.

Name: Date: Claim Number:

Accepted Conditions:

Job Title: Assistant Site Manager

Brief Job Description/Duties: Assist Site Manager in performing the daily duties and responsibilities related to the successful operation of the property. Assistant Site Managers typically live on-site.

Full time Part time Light Duty Job of Injury Transferable Skills Job Retraining Goal

Worker will: Never

Seldom 1-10% 0-1 hour

Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X X Lift lbs. 20 lbs. 5 lbs. 2 lbs. lbs. Carry lbs. lbs. 5 lbs. 2 lbs. lbs. Push / Pull lbs. 10 lbs. 5 lbs. lbs. lbs.

Optional Comments:

Approve Yes Yes, with the following modifications:

Disapprove If temporarily disapproved, for how long?

Medical Provider’s Printed Name Medical Provider’s Signature Date

F252-101-000 Job Analysis Summary 10-2014 Page 1 of 6 Index: VOC

Job Title: Assistant Site Manager DOT Code: 186.167-018

Department of Labor and Industries Physician Billing Codes

1038M – Limit one per day 1028M – Additional review, up to 5 per worker per day

Job Analysis Vocational Firm: Strategic Consulting Services, Inc. Worker: Address: 2617 12th Ct. SW., Building A

Olympia, WA 98502 Claim No.: Job Title: Assistant Site Manager DOT #: 186.167-018

Phone: 360-993-5723 Involved body parts:

Job of Injury Light Duty Position Direct/Transferable Skills Position Training Goal

Job Title: Assistant Site Manager DOT Title: Manager, Apartment House SVP: 4 DOT #: 186.167-018 Wage: Type of Industry: 731 Real Estate

Analyst: Janet Snyder, B.A., CDMS Employer: Assigned VRC: Source: Date: 06/24/2016 Phone:

Type of Analysis: On-Site Interview Representative

Brief Job Summary: Assist Site Manager in performing the daily duties and responsibilities related to the successful operation of the property. Assistant Site Managers typically live on-site.

Essential Job Functions: • Shows prospective tenants apartments and explains occupancy terms.• Informs prospective tenants of availability of nearby schools, shopping malls, recreational facilities, and

public transportation.• Rents or leases apartments, collects security deposit as required, and completes lease form outlining

conditions and terms of occupancy when required.• Collects rents due and issues receipts. Issues late notices and follows up on delinquencies.• Investigates tenant complaints concerning malfunctions of utilities or furnished household appliances or

goods, and inspects vacated apartments to determine need for repairs or maintenance.• Directs and coordinates activities of maintenance staff engaged in repairing plumbing or electrical

malfunctions, painting apartments or buildings, and performing landscaping or gardening work, or arrangesfor outside personnel to perform repairs.

• Directs and coordinates the driver and housekeeping.• Resolves tenant complaints concerning other tenants or visitors.

Training/Preparation Required: High School education and a minimum of one year experience as an Assistant Site Manager or related field; knowledge of or training in LIHT (Section 42) compliance; knowledge of computers and basic software application including Word, Excel, Outlook and where appropriate, property management software (e.g. AMSI); ability to work with other employees and address resident concerns in a professional manner; the ability to comprehend and perform all responsibilities of the position; able to assist in performing the duties of the Site Manager in his/her absence; neat, clean and professional appearance; must be able to communicate effectively in English - both verbal and written; valid driver's license with clean record and operational vehicle.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: PC computer, printer, facsimile, copier, standard office supplies, and vehicle. Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Assistant Site Manager DOT Code: 186.167-018

Claimant: Claim No.: Job Title: Assistant Site Manager Body Part Injured: DOT Code: 186.167-018

Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time O = Occasional (11-33%, 48 min. – 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. – 5 hrs. 35 min.) Heavy Hours Per Day

C = Constant (67-100%, more than 5 hrs. 35 min.) Very Heavy Days Per Week

Job Demand Frequency Activity Description % Time N S O F C

Sitting X Sit in on-site office when providing assistance to residents - documenting concerns, answering questions, collecting rents, preparing marketing materials, etc. Sitting occurs in a swivel office chair.

Standing X Stand when assisting residents with questions and concerns. Standing occurs on carpet, tile, vinyl, asphalt and concrete surfaces. Stand and walk are intermittent throughout the shift with static standing limited to under 5 minutes in duration.

Walking X Walk when meeting prospective residents and showing the community. Walking occurs on carpet, tile, vinyl, asphalt and concrete surfaces. Stand and walk are intermittent throughout the shift with walking lasting up to 30 minutes when providing tours to prospective clients or hanging notices/flyers.

Job Demand Frequency & Weight Activity Description Lifting N S O F C

lbs.

Typical office supplies, decorations.

20 5 2

Carry (Dist.) 10 ft.

N S O F C

lbs.

Carts are used to move larger and heavier items/boxes throughout the property as needed (holiday decorations, large supplies).

5 2

Pushing/ Pulling (Dist.) ft.

N S O F C lbs. of force

Open/close drawers and doors. Seldom push cart with supplies. 10 5

Job Demand Frequency Activity Description N S O F C

Perform Work on Ladders X Climb Stairs X Buildings have elevators available, but stairs may be

used in emergencies. Twisting X Must be able to twist at neck level to check blind spot

while driving.

Strategic Consulting Services, Inc.

Based on F252-072-000 12- 2015 Page 3 of 6


Job Demand Frequency Activity Description Stooping / Bending X To reach lower shelves and bottom drawer of filing

cabinets - often performed from a seated position. Crouch/kneel can often be used in lieu of bend/stoop at the employee's discretion.

Squatting / Kneeling X See Stooping/Bending. Crawling X Balancing X

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Can be performed unilaterally or bilaterally. Work Above Shoulders X Can be performed unilaterally or bilaterally. Keyboarding X Intermittently throughout the day. Seldom repetitive. Wrist Flexion/Extension X While using keyboard, computer mouse. Handle/Grasp X Simple grasping techniques requiring minimal force to

handle office supplies, equipment. Forceful Grasp X To lift heavier items. Fine Finger Manipulation X While using keyboard and other office equipment. Must

be able to write legibly. Hand Controls X Controls on office equipment, vehicle. Foot Controls X Operate vehicle. Repetitive Motion X Body part: Hands While using keyboard, but

typically this activity is intermittent.

Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X Must be able to communicate with residents, the general public and co-workers.

Hearing X Must be able to communicate with residents, the general public and co-workers.

Tasting/Smelling X Must be able to smell to verify cleanliness of "move outs", to assess safety and to evaluate complaints.

Visual - Near Acuity X Normal or corrected to normal vision is needed to perform computer work.

Visual - Far Acuity X Must be able to operate vehicle safely and assess property safety.

Visual - Depth Perception X Must be able to operate vehicle safely. Visual - Color Discrimination

X

Visual - Accommodation X Visual - Field Of Vision X


Based on F252-072-000 12- 2015 Page 4 of 6


Environmental Conditions Frequency Activity Description

N S O F C Exposure to Weather X May be exposed to inclement weather when walking

between buildings on the property. Extreme Cold X Extreme Hot X Wet and / or Humidity X May be exposed to inclement weather when walking

between buildings on the property. Proximity to Moving Mechanical Parts

X

Exposure to Explosives X Atmospheric Conditions X Exposed Heights X Exposure to Electricity X Exposure to Toxic / Caustic Chemicals

X May be exposed to some infectious diseases and cleaning agents.

Exposure to Radiation X Other: X Noise Intensity 1 = Very Quiet, 2 = Quiet,

3 = Moderate, 4 = Loud, 5 = Very Loud 3

Analyst’s Comments:

Possible Employer Modifications:

Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a “best estimate” may have been used.

Analyst:

6/26/16

Janet Snyder, B.A., CDMS Date


Based on F252-072-000 12- 2015 Page 5 of 6


Medical Provider

I agree that the above name injured worker can perform the physical activities described in this job analysis and can return to work.

State the date worker is released to return to work if different from today’s date. ___________

I agree the injured worker can perform the described job but only with modifications as described below.

Comments:

Modifications are needed on a permanent or temporary basis.

The above-named injured worker temporarily cannot perform this job based on the following physical limitations:

Anticipated release date:

Treatment plan:

The above named injured worker is permanently restricted from performing the physical activities described in this job analysis based on the following physical limitations:

(State objective medical findings)

Restriction based on accepted conditions on claim. Restriction based on unaccepted conditions on claim.

________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name

Attending Physician Consulting Physician Pain Program Physician

IME Physician PCE Therapist OT / PT Therapist


Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Cashier

Brief Job Description/Duties: Receives cash from customers in payment for goods or services and records amounts received using a cash register.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. 20 lbs. 10 lbs. 5 lbs. 1 lbs. Carry lbs. 20 lbs. 10 lbs. 5 lbs. lbs. Push / Pull lbs. lbs. lbs. lbs. 1 lbs.

Optional Comments:





Job Title: Cashier DOT Code: 211.462-010




Olympia, WA 98502 Claim No.: Job Title: Cashier DOT #: 211.462-010



Job Title: Cashier DOT Title: Cashier II SVP: 2 DOT #: 211.462-010 Wage: Type of Industry: 249, Clerical and Kindred



Brief Job Summary: Receives cash from customers in payment for goods or services and records amounts received using a cash register.

Essential Job Functions: • Required to ring up cost of food on cash register, take payments, return change and balance register at

end of the day. • May be required to assist residents to table.• May be required to carry money from facility to dining area and confirm amount.

Training/Preparation Required: Employer will provide training. Must be able to perform basic math to balance register. Must be able to communicate in English.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Cash register



Based on F252-072-000 12- 2015 Page 2 of 6


Claimant: Claim No.: Body Part Injured:



Sitting X Sitting is performed up to four hours per day while performing cashier duties. Able to alternate sitting and standing intermittently.

Standing X Standing and walking are intermittent. Walking X Standing and walking are intermittent.


lbs.

Handle money and paperwork. Seldom lift up to 20 pounds such as the till and money at the end of the day. May carry food trays to tables.

20 10 5 1


N S O F C

lbs.

Occasionally may be required to carry money and change up to 100 feet at one time to and from the cashier area. May carry food trays to tables.

20 10 5



May use minimal push/pull force to open and close the cash register drawer. 1


Perform Work on Ladders X Climb Stairs X Twisting X Stooping / Bending X Bending at the waist may be performed. Squatting / Kneeling X Crouching may be performed to pick up items dropped. Crawling X Balancing X

Strategic Consulting Services, Inc. Based on F252-072-000 12- 2015 Page 3 of 6

Claimant: Claim No.: Job Title: Cashier Body Part Injured: DOT Code: 211.462-010

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Reaching to exchange money or transport food trays. Work Above Shoulders X Keyboarding X Cash register key pad. Wrist Flexion/Extension X Minimal flexion/extension to operate cash register. Handle/Grasp X Constant handling and grasping money. Forceful Grasp X When transporting food trays. Fine Finger Manipulation X Frequent fingering when using the cash register to add

up purchases and count coins. Hand Controls X Hand controls are used on the cash register. Foot Controls X Repetitive Motion X Body part: Hands Operate cash register;

intermittent with money handling.



Talking X Talking/hearing is necessary for communicating with others and for taking instructions from others.

Hearing X Talking/hearing is necessary for communicating with others and for taking instructions from others.

Tasting/Smelling X Visual - Near Acuity X Necessary for money handling. Visual - Far Acuity X Visual - Depth Perception X Visual - Color Discrimination

X



N S O F C Exposure to Weather X Extreme Cold X Extreme Hot X Wet and / or Humidity X Proximity to Moving Mechanical Parts

X

Exposure to Explosives X Atmospheric Conditions X Exposed Heights X Exposure to Electricity X




Exposure to Toxic / Caustic Chemicals







Analyst:

2/26/16




Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Community Site Manager

Brief Job Description/Duties: Manages Senior Community complex while living on-site.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X X Lift lbs. 20 lbs. 5 lbs. 2 lbs. lbs. Carry lbs. lbs. 5 lbs. 2 lbs. lbs. Push / Pull lbs. 10 lbs. 5 lbs. lbs. lbs.

Optional Comments:





Job Title: Community Site Manager DOT Code: 186.167-018




Olympia, WA 98502 Claim No.: Job Title: Community Site Manager DOT #: 186.167-018



Job Title: Community Site Manager DOT Title: Manager, Apartment House SVP: 6 DOT #: 186.167-018 Wage: Type of Industry: 731 Real Estate



Brief Job Summary: Manages Senior Community complex while living on-site.

Essential Job Functions:

• Shows prospective tenants apartments and explains occupancy terms.• Informs prospective tenants of availability of nearby schools, shopping malls, recreational facilities, and

public transportation.• Rents or leases apartments, collects security deposit as required, and completes lease form outlining

conditions and terms of occupancy when required.• Collects rents due and issues receipts. Issues late notices and follows up on delinquencies.• Investigates tenant complaints concerning malfunctions of utilities or furnished household appliances or

goods, and inspects vacated apartments to determine need for repairs or maintenance.• Directs and coordinates activities of maintenance staff engaged in repairing plumbing or electrical

malfunctions, painting apartments or buildings, and performing landscaping or gardening work, or arrangesfor outside personnel to perform repairs.

• Directs and coordinates the driver and housekeeping.• Resolves tenant complaints concerning other tenants or visitors.

Training/Preparation Required: High School education and a minimum of four years experience as an Assistant Site Manager, Manager or related field; able to assist in performing the duties of the Site Manager in his/her absence; knowledge of or training in LIHT (Section 42) compliance; knowledge of computers and basic software application including Word, Excel, Internet, Outlook and where appropriate, property management software (e.g. AMSI); ability to work with other employees and address resident concerns in a professional manner; the ability to comprehend and perform all responsibilities of the position; neat, clean and professional appearance; must be able to communicate effectively in English - both verbal and written; valid driver's license with clean record and operational vehicle.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: PC Computer, printer, facsimile, copier, standard office supplies, and vehicle. Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Community Site Manager DOT Code: 186.167-018

Claimant: Claim No.: Job Title: Community Site Manager Body Part Injured: DOT Code: 186.167-018




Sitting X Sit in on-site office when providing assistance to residents - documenting concerns, answering questions, collecting rents, preparing marketing materials, etc. Sitting occurs in a swivel office chair.

Standing X Stand when assisting residents with questions and concerns. Standing occurs on carpet, tile, vinyl, asphalt and concrete surfaces. Stand and walk are intermittent throughout the shift with static standing limited to under 5 minutes in duration.

Walking X Walk when meeting prospective residents and showing the community. Walking occurs on carpet, tile, vinyl, asphalt and concrete surfaces. Stand and walk are intermittent throughout the shift with walking lasting up to 30 minutes when providing tours to prospective clients or hanging notices/flyers.


lbs.

Typical office supplies, decorations.

20 5 2


N S O F C

lbs.

Carts are used to move larger and heavier items/boxes throughout the property as needed (holiday decorations, large supplies).

5 2



Open/close drawers and doors. Seldom push cart with supplies. 10 5


Based on F252-072-000 12- 2015 Page 3 of 6



Perform Work on Ladders X Climb Stairs X Buildings have elevators available, but stairs may be

used in emergencies. Twisting X Must be able to twist at neck level to check blind spot

while driving. Stooping / Bending X To reach lower shelves and bottom drawer of filing

cabinets - often performed from a seated position. Crouch/kneel can often be used in lieu of bend/stoop at the employee's discretion.

Squatting / Kneeling X See Stooping/Bending. Crawling X Balancing X

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Can be performed unilaterally or bilaterally. Work Above Shoulders X Can be performed unilaterally or bilaterally. Keyboarding X Intermittently throughout the day. Seldom repetitive. Wrist Flexion/Extension X While using keyboard, computer mouse. Handle/Grasp X Simple grasping techniques requiring minimal force to

handle office supplies, equipment. Forceful Grasp X To lift heavier items. Fine Finger Manipulation X While using keyboard and other office equipment. Must

be able to write legibly. Hand Controls X Controls on office equipment, vehicle. Foot Controls X Operate vehicle. Repetitive Motion X Body part: Hands While using keyboard, but

typically this activity is intermittent.



Talking X Must be able to communicate with residents, the general public and co-workers.

Hearing X Must be able to communicate with residents, the general public and co-workers.

Tasting/Smelling X Must be able to smell to verify cleanliness of "move outs", to assess safety and to evaluate complaints.

Visual - Near Acuity X Normal or corrected to normal vision is needed to perform computer work.

Visual - Far Acuity X Must be able to operate vehicle safely and assess property safety.

Visual - Depth Perception X Must be able to operate vehicle safely. Strategic Consulting Services, Inc.

Based on F252-072-000 12- 2015 Page 4 of 6


Job Demand Frequency Activity Description Visual - Color Discrimination

X



N S O F C Exposure to Weather X May be exposed to inclement weather when walking

between buildings on the property. Extreme Cold X Extreme Hot X Wet and / or Humidity X May be exposed to inclement weather when walking

between buildings on the property. Proximity to Moving Mechanical Parts

X








Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 5 of 6


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Cook Helper

Brief Job Description/Duties: Assists Dietary cook in preparing foods.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift >50 lbs. 26-50 lbs. 11-25 lbs. 10 lbs. <10 lbs. Carry >50 lbs. 26-50 lbs. 11-25 lbs. 10 lbs. <10 lbs. Push / Pull lbs. lbs. <10 lbs. lbs. 2 lbs.

Optional Comments:





Job Title: Cook Helper DOT Code: 317.687-010




Olympia, WA 98502 Claim No.: Job Title: Cook Helper DOT #: 317.687-010



Job Title: Cook Helper DOT Title: Cook Helper SVP: 2 DOT #: 317.687-010 Wage: Type of Industry: 453, Hotel Restaurant



Brief Job Summary: Assists Dietary cook in preparing foods.

Essential Job Functions: • May wash, peel, cut and seed vegetables and fruit.• Cleans, cuts and grinds meats, poultry and seafood.• May weigh and measure designated ingredients for recipe.• Prepare salads, deserts and other side dishes.• May prepare coffee and hot water.• May wash all pots and knives used.• May prepare trays for residents.• Assist in cleaning of work area at the end of shift.• Employee is required to handle food throughout the day.• Employee must be able to be on feet all day. Also must be able to keep pace with a busy kitchen to ensure

that food is prepared and ready for serving on time.

Training/Preparation Required: Prior experience with food preparation. Food Handler's Permit.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Meat slicer, food processor, mixer, oven, steamer, spoons, knives, can openers, measuring spoons/cups, other kitchen equipment and supplies.

Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Cook Helper DOT Code: 317.687-010

Claimant: Claim No.: Job Title: Cook Helper Body Part Injured: DOT Code: 317.687-010




Sitting X Sitting is only allowed on breaks and at lunch. Standing X Standing is performed for three to six hours out of

an eight-hour day on tile floor, intermittent with walking for a total of eight hours per day. Some floor surfaces may be wet when dish washing or from food dropped on the floor.

Walking X Walking is performed for one to two hours at a time on tile floor. Some floor surfaces may be wet when dish washing or from food dropped on the floor.


lbs.

Lifting up to 10 pounds of meats when slicing is required. May also be required to lift various canned items weighing up to three pounds at a time. Lifting up to 25-pound boxes of vegetables may be required. Lifting up to 50-pound boxes of kale, lettuce or bags of potatoes may be required.

>50 26-50 11-25 10 <10


N S O F C

lbs.

Frequently required to carry prepared foods weighing up to 10 pounds from preparation area to walk-in refrigerator. Carrying boxes of vegetables may be required. Up to 50 pound bags of potatoes may need to be carried.

>50 26-50 11-25 10 <10



Occasionally required when using food cart to move items through kitchen. <10 2


Based on F252-072-000 12- 2015 Page 3 of 6



Perform Work on Ladders X Climb Stairs X Twisting X Occasional twisting at waist may occur while preparing

food. Stooping / Bending X Frequent bending may occur while cleaning work area

or obtaining items from lower shelves. Squatting / Kneeling X Occasional crouching may occur while cleaning or

retrieving food items from lower shelves. Crawling X Balancing X

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Constant reaching when preparing food. Reaching

below waist level is occasionally required when cleaning the kitchen area.

Work Above Shoulders X Reaching above shoulder height is occasionally required when reaching for food items on higher shelves.

Keyboarding X Wrist Flexion/Extension X While preparing food. Handle/Grasp X Constant handling and grasping is required while

preparing food items. Forceful Grasp X Required while using implements and while lifting heavy

items. Fine Finger Manipulation X While working with food. Hand Controls X Operate kitchen equipment. Foot Controls X Repetitive Motion X Body part: Hands During food preparation. Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X Necessary to communicate with others and for taking instructions from others.

Hearing X Necessary to communicate with others and for taking instructions from others.

Tasting/Smelling X The ability to taste and smell is a requirement of this position.

Visual - Near Acuity X Necessary to do the job effectively and correctly. Visual - Far Acuity X Visual - Depth Perception X Necessary to do the job effectively and correctly.


Based on F252-072-000 12- 2015 Page 4 of 6



X



N S O F C Exposure to Weather X Extreme Cold X Walk-in refrigerator. Extreme Hot X Ovens. Wet and / or Humidity X Proximity to Moving Mechanical Parts

X


X






Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 5 of 6


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Daycare Worker

Brief Job Description/Duties: Organize and lead activities of pre-kindergarten children. Provide a warm, nurturing, safe and loving environment where self-concepts are enhanced, independence encouraged, and individuality respected.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. 51-70 lbs. 26-50 lbs. 10-25 lbs. <2 lbs. Carry lbs. 51-70 lbs. 26-50 lbs. 10-25 lbs. <2 lbs. Push / Pull lbs. lbs. lbs. 10 lbs. lbs.

Optional Comments:





Job Title: Daycare Worker DOT Code: 359.677-018




Olympia, WA 98502 Claim No.: Job Title: Daycare Worker DOT #: 359.677-018



Job Title: Daycare Worker DOT Title: Nursery School Attendant SVP: 4 DOT #: 359.677-018 Wage: Type of Industry: 138, Any Industry



Brief Job Summary: Organize and lead activities of pre-kindergarten children. Provide a warm, nurturing, safe and loving environment where self-concepts are enhanced, independence encouraged, and individuality respected.

Essential Job Functions: • Interact with children.• Plan weekly lessons.• Maintain good communications with parents.• Observe and record behavior, use appropriate discipline, and maintain records and files.• Keep staff informed of program goals and developments and attend meetings and inservices.• Prepare materials for the programs and report to the supervisor.• Change and plan activities and room arrangements as needed.• Perform other miscellaneous duties.

Training/Preparation Required: Early childhood education is preferred. It is necessary to have CPR, First Aid, and HIV training. Must be 18 years old, have good communication skills, must not have been convicted of child abuse or any crime involving harm to another person. Evidence of emotional maturity and stability. Flexibility to accept changes in staffing patterns. Tolerance of different aspects of parenting and cultural background.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Toys, cleaning equipment, carts and a multitude of learning supplies.

Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Daycare Worker DOT Code: 359.677-018

Claimant: Claim No.: Job Title: Daycare Worker Body Part Injured: DOT Code: 359.677-018




Sitting X Intermittent throughout the day while reading stories to children or assisting with program activities. Sitting may be performed at a standard desk, on the floor, or other seating arrangements. Sitting is usually not performed for more than two hours per day.

Standing X The majority of the day up to six to seven hours is performed while standing and walking around the Day Care facility at the nursing home site. Walking and standing would be performed on both carpeting and linoleum surfaces anywhere from 15 to 60 minutes at a time, depending on the specific activity.

Walking X The majority of the day, up to six to seven hours, job duties are performed while standing and walking around the Day Care facility at the nursing home site. Walking and standing would be performed on both carpeting and linoleum surfaces anywhere from 15 to 60 minutes at a time, depending on the specific activity.


lbs.

Lift books, toys and other items. Lift from 10 to 25 pounds while working with infants and using supplies and equipment. May lift up to 50 pounds while working with pre-school children or moving tables and chairs. Rarely, may be required to lift over 50 pounds if an older child is hurt.

51-70 26-50 10-25 <2


N S O F C

lbs.

There is frequent carrying of 10 to 25 pounds, and occasional to rare carrying of items up to 50 pounds and over 50 pounds. Maximum distance may be 100 to 200 feet.

51-70 26-50 10-25 <2


N S O F C

lbs. of force

There is frequent pushing and pulling performed to rearrange furniture, push a lunch cart, performing cleaning activities or other related tasks.

10




Perform Work on Ladders X Climb Stairs X There is seldom climbing of stairs performed while

performing activities in this position. Twisting X There is frequent twisting at the waist and neck while

taking part in developmental activities. Stooping / Bending X There is frequent bending at the waist while working

with the children as it is necessary to perform activities at their level.

Squatting / Kneeling X Frequent kneeling and squatting are also performed in this position while performing activities with the children.

Crawling X Crawling would be performed occasionally while taking part in developmental activities.

Balancing X

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Reaching is performed from ground level to overhead

on a frequent basis. Bilateral reach is required. Work Above Shoulders X Reaching is performed from ground level to overhead

on a frequent basis. Bilateral reach is required. Keyboarding X May be required to track information on the computer. Wrist Flexion/Extension X When keyboarding. Handle/Grasp X Frequent handle/grasp when engaging in activities. Forceful Grasp X When lifting heavy items. Fine Finger Manipulation X Is performed occasionally when doing activities with the

children including drawing, cutting, etc. Hand Controls X May use hand controls on equipment. Foot Controls X No use of foot controls. Repetitive Motion X Body part: Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X Must have excellent communication skills and be able to interact appropriately with children, parents and co-workers.

Hearing X Must have excellent communication skills and be able to interact appropriately with children, parents and co-workers.

Tasting/Smelling X Must be able to detect emergencies (i.e. fire) and determine when diapers need to be changed.

Visual - Near Acuity X Must be able to observe the work environment and the children in order to ensure their safety. Must be able to read books.



Job Demand Frequency Activity Description Visual - Far Acuity X Must be able to observe the work environment and the

children in order to ensure their safety. Visual - Depth Perception X Must be able to observe the work environment and the

children in order to ensure their safety. Visual - Color Discrimination

X When working on developmental activities with children.

Visual - Accommodation X To perform various job duties. Visual - Field Of Vision X Must be able to observe the work environment and the

children in order to ensure their safety.



X


X Some cleaning supplies.

Exposure to Radiation X Other: May change soiled diapers.

X

Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud

3




Analyst:

6/26/16

Janet Snyder, B.A., CDMS Date Strategic Consulting Services, Inc.

Based on F252-072-000 12- 2015 Page 5 of 6


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Dietary Cook

Brief Job Description/Duties: Prepares and cooks meals for residents and employees.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift >50 lbs. 26-50 lbs. 11-25 lbs. 10 lbs. <10 lbs. Carry lbs. 26-50 lbs. 11-25 lbs. 10 lbs. <10 lbs. Push / Pull lbs. lbs. 2 lbs. lbs. lbs.

Optional Comments:





Job Title: Dietary Cook DOT Code: 315.361-010




Olympia, WA 98502 Claim No.: Job Title: Dietary Cook DOT #: 315.361-010



Job Title: Dietary Cook DOT Title: Cook SVP: 6 DOT #: 315.361-010 Wage: Type of Industry: 138, Any Industry



Brief Job Summary: Prepares and cooks meals for residents and employees.

Essential Job Functions: • Cooks food in quantities according to the menu and number of persons to be served.• Plans menu, taking advantage of foods in season and local availability.• May serve meals.• May order supplies and keep records and accounts.• May direct activities of one or more workers who assist in preparing and serving meals.• Prepare various foods depending on menu created by dietitians, for each meal of the day.• Operate kitchen equipment in preparation for meals.• Required to clean work surfaces following shift: sweep floors, wipe down counter space, cover and store

unused foods.• Must be able to create meals that are appropriate for the elderly and in large quantities.• Employee is required to use institutional size cookware.• Must be able to work at a constant pace to ensure the food is ready for each meal of the day.• Employee is required to handle food throughout the day. Types of foods: meats, raw vegetables, fresh

fruit, canned foods.

Training/Preparation Required: A minimum of 1-2 years training/experience.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Spoons, knives, can openers, measuring spoons/cups, meat slicer, stove, oven, food processor, blender, various pots and pans, and other kitchen equipment and supplies.

Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Dietary Cook DOT Code: 315.361-010

Claimant: Claim No.: Job Title: Dietary Cook Body Part Injured: DOT Code: 315.361-010




Sitting X Sitting is only performed during breaks. Standing X Static standing and walking are alternated

throughout the day. Some floor surfaces may be wet from dish washing or from food dropped on the floor.

Walking X Walking short distances is intermittent with standing throughout the day. Some floor surfaces may be wet from dish washing or from food dropped on the floor.


lbs.

Frequent lifting of up to 10 pounds is required when preparing various food items and using kitchen equipment, i.e. cutting five pound hams on industrial size slicer. Occasional lifting up to 25 pounds when lifting items filled with soup or stew. Lifting up to 50 pounds is rarely required when lifting a 50-pound bag of potatoes - this can be deferred to other workers if the employee is not able to lift this amount.

>50 26-50 11-25 10 <10


N S O F C

lbs.

Carrying up to 10 pounds is frequently required when carrying various food items within the kitchen area, usually a distance of five to 20 feet. Carrying up to 25 pounds may be rarely required to carry filled pots from one burner to another. Carrying up to 50 pounds is required on a rare basis when carrying a 50-pound bag of potatoes.

26-50 11-25 10 <10



Occasionally may be required when pushing and pulling baking sheets to and from the oven with little resistance.

2




Perform Work on Ladders X Climb Stairs X Twisting X Occasional twisting at the waist while cooking. Stooping / Bending X Frequent bending at the waist is performed in the

course of performing the various job tasks. Squatting / Kneeling X Occasional crouching while retrieving items from lower

shelves. Crawling X Crawling is not a requirement of this position. Balancing X

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Reaching from 1/2 to full arm extension is required.

Occasional reaching below waist level. Work Above Shoulders X Reaching above shoulder level is occasionally required

when reaching for food items in refrigerator or spices on shelves.

Keyboarding X Wrist Flexion/Extension X While cooking food. Handle/Grasp X Constant handling and grasping is performed in this

position while performing job tasks. Forceful Grasp X Constant while holding implements or lifting heavy

items. Fine Finger Manipulation X While cooking food and operating controls. Hand Controls X Hand controls such as push buttons, turn knobs, and

dials are intermittently used throughout the work shift. Foot Controls X Repetitive Motion X Body part: Hands While cooking. Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X Necessary for communicating with others and for taking instructions from others.

Hearing X Necessary for communicating with others and for taking instructions from others.

Tasting/Smelling X Necessary for testing quality of food products. Visual - Near Acuity X Necessary for testing quality of food products. Visual - Far Acuity X Visual - Depth Perception X Necessary to do the job effectively and correctly. Visual - Color Discrimination

X

Visual - Accommodation X Visual - Field Of Vision X Must be able to see full range of visual field.




N S O F C Exposure to Weather X Extreme Cold X Walk-in refrigerator. Extreme Hot X Ovens. Wet and / or Humidity X Proximity to Moving Mechanical Parts

X


X






Analyst:

2/26/16



Claimant: Claim No.: Job Title Dietary Cook Body Part Injured: DOT Code: 315.361-010

Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Dishwasher

Brief Job Description/Duties: Assist in maintaining kitchen work areas and keeping equipment, utensils and food plates clean and orderly.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. lbs. 20-50 lbs. <25 lbs. <10 lbs. Carry lbs. lbs. 20-50 lbs. <25 lbs. <10 lbs. Push / Pull lbs. lbs. lbs. <10 lbs. lbs.

Optional Comments:





Job Title: Dishwasher DOT Code: 318.687-010




Olympia, WA 98502 Claim No.: Job Title: Dishwasher DOT #: 318.687-010



Job Title: Dishwasher DOT Title: Kitchen Helper SVP: 2 DOT #: 318.687-010 Wage: Type of Industry: 453, Hotel & Restaurant



Brief Job Summary: Assist in maintaining kitchen work areas and keeping equipment, utensils and food plates clean and orderly.

Essential Job Functions: • Ability to operate industrial dishwater and to perform repetitive work according to set procedures.• Sweep and mop floors of kitchen and may be required to sweep and mop dining area.• May be required to wash food preparation work tables, walls, refrigerators and refrigerated walk-ins.• Required to remove garbage from kitchen area and hose out garbage containers.

Training/Preparation Required: This job can be learned through on the job training.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Dishwasher, rolling carts, dish tubs, mop and broom.



Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Dishwasher DOT Code: 318.687-010

Claimant: Claim No.: Job Title: Dishwasher Body Part Injured: DOT Code: 318.687-010


Sitting X Sitting is only performed during breaks. Standing X Static standing is performed while operating

dishwasher, intermittent with walking on tiled floor surface. Some floor surfaces may be wet when dish washing or from food dropped on the floor.

Walking X Walking frequently, intermittent with standing while performing job tasks. Some floor surfaces may be wet when dish washing or from food dropped on the floor.


lbs.

Lift trays of dishes to be loaded and unloaded into the dishwasher. Occasional lifting of up to 20-pound buckets of ice.

20-50 <25 <10


N S O F C lbs.

The items lifted may be carried a distance of approximately 5-20 feet. 20-50 <25 <10



Push carts of dishes and when pushing the trays into and out of the dishwasher. <10


Perform Work on Ladders X Climb Stairs X Twisting X At waist and neck level while washing dishes. Stooping / Bending X While performing job duties. Squatting / Kneeling X Crouching may be performed at the discretion of the

worker in place of bending as appropriate. Crawling X Balancing X

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X To operate the dishwasher and perform regular job

tasks. Work Above Shoulders X To access high shelves. Keyboarding X Wrist Flexion/Extension X To wash dishes. Handle/Grasp X Repetitive arm and hand motions are used to load and

unload the dishwasher and clean food off plates. Twist at wrist level.

Forceful Grasp X To lift heavy items.


Based on F252-072-000 12- 2015 Page 3 of 6


Job Demand Frequency Activity Description Fine Finger Manipulation X Intermittently operate dials and controls on the

equipment while utilizing manual and finger dexterity. Hand Controls X Intermittently operate dials and controls on equipment

while utilizing manual and finger dexterity. Foot Controls X Repetitive Motion X Body part: Arm/Hands Repetitive arm and hand

motions are used to load and unload the dishwasher and clean food off plates.



Talking X Must be able to communicate with co-workers and supervisors.

Hearing X Must be able to communicate with co-workers and supervisors.

Tasting/Smelling X Visual - Near Acuity X Must be able to determine if dishes are clean. Visual - Far Acuity X Visual - Depth Perception X Visual - Color Discrimination

X



N S O F C Exposure to Weather X Extreme Cold X Walk in refrigerator. Extreme Hot X Ovens. Wet and / or Humidity X Dishwasher. Proximity to Moving Mechanical Parts

X


X Some cleaning supplies.

Exposure to Radiation X Other: X


Based on F252-072-000 12- 2015 Page 4 of 6




4




Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 5 of 6


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Driver

Brief Job Description/Duties: Drives shuttle van to transport passengers to and from stores, planned lunches, post office, library and other planned outings.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. 45 lbs. 20 lbs. 2 lbs. lbs. Carry lbs. 45 lbs. 20 lbs. 2 lbs. lbs. Push / Pull lbs. 25 lbs. lbs. lbs. lbs.

Optional Comments:





Job Title: Driver DOT Code: 913.663-018




Olympia, WA 98502 Claim No.: Job Title: Driver DOT #: 913.663-018



Job Title: Driver DOT Title: Driver SVP: 3 DOT #: 913.663-018

Wage: Type of Industry: 593 Motor Vehicle Transportation



Brief Job Summary: Drives shuttle van to transport passengers to and from stores, planned lunches, post office, library and other planned outings.

Essential Job Functions: • Provide transportation based on monthly events calendar from manager.• Assist residents in and out of van.• Assist with securing/storage of wheelchairs/walkers and purchased items.• Maintain cleanliness of vans, keep vans full of petrol and notify management of vehicle mechanical

operation concerns.

Training/Preparation Required: Must be at least 18 years old; experience preferred. Must have driver's license and be insurable. Must have clean record. Must be able to communicate in English.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: 12 passenger bus and 8 passenger van, cleaning supplies, writing implement and clip board.



Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Driver DOT Code: 913.663-018

Claimant: Claim No.: Job Title: Driver Body Part Injured: DOT Code: 913.663-018


Sitting X While driving, up to 30 minutes at a time. Standing X Alternated with frequent walking and sitting. Walking X Walk between parking lot and residence; most often

on concrete or asphalt. Alternated with sitting and standing.


lbs.

Lift items such as pen/pencil, cleaning supplies, groceries, shopping bags, and walkers (can weigh up to 20 pounds). SELDOM lift/carry up to 45 pounds less than 10 feet when storing wheelchairs.

45 20 2


N S O F C

lbs.

Carry items such as pen/pencil, cleaning supplies, groceries, shopping bags, and walkers (can weigh up to 20 pounds). SELDOM lift/carry up to 45 pounds less than 10 feet when storing wheelchairs.

45 20 2


N S O F C

lbs. of force

Push/pull vehicle doors and straps to secure wheelchairs in place. SELDOM use 25 pounds force to push/pull wheelchairs into place in the van or to assist residents in/out of the van.

25


Perform Work on Ladders X Climb Stairs X Climb three steps in and out of vans. Twisting X At neck level while checking blind spot. May twist at

waist to secure wheelchairs. Stooping / Bending X Assist residents to enter/exit van and to store items in

cargo space. Squatting / Kneeling X May crouch when accessing folding mechanism for van

chair 3 times per week. May choose to crouch in lieu of stooping.

Crawling X May be required when accessing folding mechanism for van chair roughly 3 times per week.

Balancing X

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X While driving, storing purchases and assisting residents.

May also occasionally reach below waist level. Work Above Shoulders X To store items. Keyboarding X Wrist Flexion/Extension X



Job Demand Frequency Activity Description Handle/Grasp X Steering wheel, pen/pencil, wheelchairs, walkers,

shopping bags and additional supplies. Forceful Grasp X Steering wheel, pen/pencil, wheelchairs, walkers,

shopping bags and additional supplies. Fine Finger Manipulation X Perform various job duties. Hand Controls X Vehicle controls. Foot Controls X Vehicle controls. Repetitive Motion X Body part: Vibratory Tasks - Low X Vibratory Tasks - High X

Job Demand Frequency Activity Description N S O F C Talking X Must be able to communicate with residents and co-

workers. Hearing X Must be able to communicate with residents and co-

workers. Tasting/Smelling X Visual - Near Acuity X Must be able to pass driving exam and read/write in

English. Visual - Far Acuity X Must be able to pass driving exam. Visual - Depth Perception X Must be able to pass driving exam. Visual - Color Discrimination

X

Visual - Accommodation X Visual - Field Of Vision X Must be able to navigate traffic and pass driving exam.


N S O F C Exposure to Weather X When getting in/out of vehicle. Extreme Cold X Extreme Hot X Wet and / or Humidity X During inclement weather. Proximity to Moving Mechanical Parts

X



Exposure to Radiation X Other: X Noise Intensity 1 = Very Quiet, 2 = Quiet, 3 = Moderate, 4 = Loud, 5 = Very Loud

4






Analyst:

6/26/16




Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Feeder/Bedmaker

Brief Job Description/Duties: Provide additional assistance to housekeeping and nursing staff.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. 50-100 lbs. 25-50 lbs. 10 lbs. lbs. Carry lbs. lbs. lbs. 10 lbs. lbs. Push / Pull lbs. lbs. lbs. 10 lbs. lbs.

Optional Comments:





Job Title: Feeder/Bedmaker DOT Code: 355.674-014




Olympia, WA 98502 Claim No.: Job Title: Feeder/Bedmaker DOT #: 355.674-014



Job Title: Feeder/Bedmaker DOT Title: Nurse Assistant SVP: 3 DOT #: 355.674-014 Wage: Type of Industry: 573, Medical Services



Brief Job Summary: Provide additional assistance to housekeeping and nursing staff.

Essential Job Functions: • Assist in changing residents' bed linens and feeding residents their meals in the dining area.• Fill the utility cart with clean linens to take to the individual residents rooms, chang linens on residents beds

(remove soiled linens and replace with clean ones).• Assist in passing out fresh water to residents and picking up the used water pitchers.• May be required to turn mattresses, checking for any tears in the mattress.• Assist residents to the dining room.• Pass food trays to individual residents in accordance with the diet card on the tray.• Document the intake of the residents on a specified card. Assist in the feeding of residents that require this

help.• Stock the utility rooms with clean linens from the laundry area.• May be required to clean residents' combs and brushes.

Training/Preparation Required: Prior training or experience is preferred.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Linen cart and supply cart.

Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Feeder/Bedmaker DOT Code: 355.674-014

Claimant: Claim No.: Job Title: Feeder/Bedmaker Body Part Injured: DOT Code: 355.674-014




Sitting X Only during breaks and lunch. Standing X Alternated with walking on a carpeting, linoleum and

tile floors. Walking X Alternated with standing on carpeting, linoleum and

tile floors.


lbs.

Lift up to 10 pounds (i.e. stacks of linens). Lift 25-50 pounds to flip mattresses on a weekly basis. Lift over 50 pounds, up to 100 pounds, to assist in transfer of a resident from a bed to a wheelchair.

50-100 25-50 10


N S O F C

lbs.

Carry up to 10 pounds of bed linens from a cart into rooms, up to 10 feet. Carrying over 10 pounds is not required for this position.

10


N S O F C

lbs. of force

Pushing is required when wheeling the laundry cart from the utility area to the rooms. The utility cart rolls easily across carpeting or tile floors.

10


Perform Work on Ladders X Climb Stairs X Twisting X Twisting at the waist while changing bed linens. Stooping / Bending X Bending may occur while assisting resident from bed to

wheelchair or while assisting in feeding of residents. Squatting / Kneeling X At the discretion of the worker, while changing bed

linen. Crawling X Balancing X


Based on F252-072-000 12- 2015 Page 3 of 6


Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X To make beds or feed residents. Bilateral reach is

required. Work Above Shoulders X When restocking utility room with clean linens from

laundry area. Keyboarding X Wrist Flexion/Extension X Handle/Grasp X Bed linens, eating utensils, etc. Forceful Grasp X Bed linens, eating utensils, etc. Fine Finger Manipulation X Intermittently performed while assisting with residents

with feeding. Hand Controls X To perform job duties. Foot Controls X Repetitive Motion X Body part: Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X Necessary for communicating with others and for taking instruction from others.

Hearing X Necessary for communicating with others and for taking instruction from others.

Tasting/Smelling X In order to detect soiled sheets. Visual - Near Acuity X To perform job duties. Visual - Far Acuity X To perform job duties. Visual - Depth Perception X Visual - Color Discrimination

X To perform job duties.




X

Exposure to Explosives X Atmospheric Conditions X Exposed Heights X Exposure to Electricity X


Based on F252-072-000 12- 2015 Page 4 of 6



Exposure to Toxic / Caustic Chemicals


Exposure to Radiation X Other: Soiled sheets. X Noise Intensity 1 = Very Quiet, 2 = Quiet,





Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 5 of 6


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Home Care Specialist

Brief Job Description/Duties: Cares for elderly, convalescent or disabled person in his/her home.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. 25 lbs. 20 lbs. 10 lbs. lbs. Carry lbs. lbs. lbs. 10 lbs. lbs. Push / Pull lbs. 25 lbs. 10 lbs. lbs. lbs.

Optional Comments:





Job Title: Home Care Specialist DOT Code: 354.377-014




Olympia, WA 98502 Claim No.: Job Title: Home Care Specialist DOT #: 354.377-014



Job Title: Home Care Specialist DOT Title: Home Attendant SVP: 3 DOT #: 354.377-014 Wage: Type of Industry: 674 Personal Service



Brief Job Summary: Cares for elderly, convalescent or disabled person in his/her home.

Essential Job Functions: • Change bed linens.• Wash and iron patient's laundry.• Perform light cleaning of patient's residence, which includes light vacuuming, washing dishes, dusting,

sweeping and wiping counters.• Purchase, prepare, and serve food for patient.• Assist patient in dressing and grooming including nail and hair care.• Assist with toilet use, changing bed pans, emptying catheter bags,assist with changing colostomy bag, and

assist with undergarments.• Assist with ambulation and transfers, and changes position of patients that are bed riden.• Ensure that patient takes prescribed medications.• Accompany patient outside home, serving as guide, companion and aide.• Perform a variety of miscellaneous duties as requested, such as obtaining household supplies and running

errands.• May maintain records of services performed and of apparent condition of patient.• May visit several households to provide daily health care to patients.• Must be able to perform CPR.

Training/Preparation Required: Prior experience is preferred. Any required training is provided to the worker after hire, such as Orientation, "Fundamentals of Care Giving" and CPR courses. A clean criminal background (via State Patrol and DSHS) is required as is a Washington State Driver's License (WSDL).

Based on F252-072-000 12- 2015 Page 2 of 7

Job Title: Home Care Specialist DOT Code: 354.377-014

Claimant: Claim No.: Job Title: Home Care Specialist Body Part Injured: DOT Code: 354.377-014

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Walker, wheelchair, cane, crutches, gait belt, personal vehicle, exercise equipment, ace bandages, grocery cart, vacuum, mop, buckets, broom, snow shovel, washing machine, dryer, iron, needle, thread, sewing machine, stove, oven, microwave, pots and pans, can opener, blender, mixers, knives, kitchen utensils, hair brush, comb, nail files, razor, hospital beds, charts, portable commode, catheter, colostomy bag, urinal, bed pan. Safety equipment includes gloves.




Sitting X Alternated with standing and walking. Standing X Alternated with sitting and walking. Walking X Alternated with sitting and standing on asphalt,

concrete, carpet, tile, etc.


lbs.

Lift items like linens, grooming implements, cooking utensils, and bags of groceries weighing negligible ounces up to 10 lbs. Employee lifts up to 20 lbs. OCCASIONALLY. On a SELDOM basis the employee will lift items that weigh up to 25 lbs.

25 20 10


N S O F C

lbs.

Items will be carried for short distances within stores, household, and medical facility – could be 5-10 feet, up to 50 feet. When shopping, an employee can utilize a cart.

10


N S O F C

lbs. of force

Utilizes up to 10 lbs. of push/pull force to vacuum, push cart, and perform various other duties throughout the workday. Employee will seldom utilize up to 25 lbs. of push/pull force to assist client with ambulation, transfers and turning in bed: please note that employee is not to lift patient and should utilize assistive devices as needed. Push wheelchairs on a seldom basis. In regards to pushing wheelchairs the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require

25 10



Job Demand Frequency & Weight Activity Description 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. Each employee performs CPR on a SELDOM basis. CPR is needed 1-2 times per week throughout the facility and multiple employees perform this function. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives – typically 1-4 minutes.


Perform Work on Ladders X Climb Stairs X May climb stairs at the patient's home; however, if the

patient does not have any stairs at the residence, then this would not be a requirement. The employee is NOT to climb on chairs or ladders, but may utilize a sturdy 2-step stool that has handrails.

Twisting X Twists at the waist, neck and wrist levels when performing regular duties. Employee can reduce twisting at the waist level by re-positioning the entire body.

Stooping / Bending X Bends at the waist when performing regular duties, such as making beds, helping with bathing and/or dressing, etc. Employee may substitute crouching or kneeling for bending at the waist at his/her own discretion. Please note that the employee must have the ability to perform CPR.

Squatting / Kneeling X On a rare basis, may need to kneel or crouch to retrieve items at floor level or to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee’s discretion.

Crawling X Balancing X

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Reach out in front of the body to assist patient with

ADLs, feeding, cleaning, and other similar duties. Work Above Shoulders X Overhead reaching to retrieve supplies on high shelves

and reaching below the waist level may occur OCCASIONALLY.

Keyboarding X



Job Demand Frequency Activity Description Wrist Flexion/Extension X Handle/Grasp X A variety of items including cooking utensils, food items,

grooming implements, etc. Handling/grasping is light in nature.

Forceful Grasp X To perform some job duties. Fine Finger Manipulation X When preparing food, clipping patient's nails, and when

writing. Hand Controls X Operates/uses controls on oven, washer/dryer, vacuum,

vehicle, etc. Foot Controls X To operate vehicle. Repetitive Motion X Body part: Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X Employee must be able to communicate with patients. Hearing X Employee must be able to communicate with patients. Tasting/Smelling X Must be able to assess cleanliness and danger. Visual - Near Acuity X To perform job duties. Visual - Far Acuity X While driving. Visual - Depth Perception X While driving. Visual - Color Discrimination


Visual - Accommodation X To perform job duties. Visual - Field Of Vision X To perform job duties.




N S O F C Exposure to Weather X While walking outside. Extreme Cold X Extreme Hot X Wet and / or Humidity X During inclement weather. Proximity to Moving Mechanical Parts

X



Exposure to Radiation X Other: Soiled sheets/clothes.

X


2




Analyst:

6/26/16




Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 7 of 7





Job Title: Homemaker

Brief Job Description/Duties: Responsible for the delivery of care to the residents living in the independent living dwellings.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. 25-50 lbs. lbs. 10 lbs. lbs. Carry lbs. 25 lbs. lbs. 10 lbs. lbs. Push / Pull lbs. lbs. 5 lbs. lbs. lbs.

Optional Comments:





Job Title: Homemaker DOT Code: 309.674-014




Olympia, WA 98502 Claim No.: Job Title: Homemaker DOT #: 309.674-014



Job Title: Homemaker DOT Title: Personal Attendant SVP: 3 DOT #: 309.674-014 Wage: Type of Industry: 319, Domestic Services



Brief Job Summary: Responsible for the delivery of care to the residents living in the independent living dwellings.

Essential Job Functions: • Perform some housecleaning; i.e., dusting, mopping, vacuuming, laundry, etc.• May be required to grocery shop for residents.• May be required to prepare meals for residents.• May be required to assist in bathing and dressing of residents.• Responsible for notifying the nursing staff of the condition of the residents if the condition has changed and

the need for further medical care is warranted.

Training/Preparation Required: Employee must be able to communicate effectively, verbally and in writing. Must be able to work well with others and especially the elderly. Must be able to problem-solve and work well alone. Valid Washington State Drivers License, personal vehicle, and auto insurance with clean dirving record. Prior experience is preferred. Any required training is provided to the worker after hire. A clean criminal background (via State Patrol and DSHS).

Machine, Tools, Special Equipment, Personal Protective Equipment Used: May be required to operate an automobile and cleaning equipment as well as kitchen appliances.



Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Homemaker DOT Code: 309.674-014

Claimant: Claim No.: Job Title: Homemaker Body Part Injured: DOT Code: 309.674-014


Sitting X Alternated with standing and walking. Standing X Alternated with walking on varying floor surfaces

including carpet, linoleum, tile and concrete for up to three hours a day.

Walking X Alternated with standing on varying floor surfaces including carpet, linoleum, tile and concrete for up to three hours a day.


lbs.

Lifting up to 10 pounds is required when performing various housecleaning duties; i.e., vacuuming, emptying garbage containers, etc. Lifting of up to 25 pounds occurs when lifting groceries if resident requires this service. Lifting up to and over 50 pounds is rarely required to assist resident in bathing which may result in bearing weight of resident with some assistance.

25-50 10

Carry (Dist.) ft.

N S O F C

lbs.

Carrying up to 10 pounds is required when performing various housecleaning duties; i.e., vacuuming, emptying garbage containers, etc. Carrying up to 25 pounds may be required when grocery shopping for resident. Carrying over 25 pounds is not required.

25 10



Occasional pushing/pulling while vacuuming residence. 5


Perform Work on Ladders X Climb Stairs X May climb stairs, up to two to three flights. Elevators are

typically available. Twisting X Twisting at the waist may occur while performing

cleaning duties or doing laundry. Twist at neck while driving.

Stooping / Bending X Bending at the waist occurs while dusting and cleaning. Squatting / Kneeling X Crawling X Balancing X

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C


Based on F252-072-000 12- 2015 Page 3 of 6


Job Demand Frequency Activity Description Reach Waist to Shoulder X To perform job duties. Work Above Shoulders X May occur when housecleaning or placing food items on

shelves for resident after shopping. Keyboarding X Wrist Flexion/Extension X Handle/Grasp X Handling of objects of varying sizes and weights such

as canned foods, cleaning supplies, etc. Forceful Grasp X Handling of objects of varying sizes and weights such

as canned foods, cleaning supplies, etc. Fine Finger Manipulation X To perform job duties. Hand Controls X Use of foot controls and hand controls are required

when driving a vehicle to perform shopping for residents. Will operate kitchen appliances.

Foot Controls X Use of foot controls and hand controls are required when driving a vehicle to perform shopping for residents.

Repetitive Motion X Body part: Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X Necessary for communicating and taking instructions from others.

Hearing X Necessary for communicating and taking instructions from others.

Tasting/Smelling X May be used when cooking for the resident or smelling chemicals/smoke or cleanliness.

Visual - Near Acuity X To perform job duties. Visual - Far Acuity X Must be able to safely drive. Visual - Depth Perception X Must be able to safely drive. Visual - Color Discrimination


Visual - Accommodation X Visual - Field Of Vision X Must be able to safely drive.


N S O F C Exposure to Weather X While walking to/from vehicle. Extreme Cold X Extreme Hot X Wet and / or Humidity X During inclement weather. Proximity to Moving Mechanical Parts

X


Based on F252-072-000 12- 2015 Page 4 of 6





Exposure to Radiation X Other: Soiled sheets/clothing

X


2




Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 5 of 6


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Housekeeper – Assisted Living

Brief Job Description/Duties: Provide cleaning service to maintain clean rooms and common areas for assisted living residents. Worker will clean five residential units per day. Linens are changed by the Resident Service Associates (RSA) not Housekeeping.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. 20 lbs. lbs. 5 lbs. lbs. Carry lbs. 20 lbs. lbs. 5 lbs. lbs. Push / Pull lbs. lbs. 15 lbs. 5 lbs. lbs.

Optional Comments:





Job Title: Housekeeper – Assisted Living DOT Code: 323.687-014




Olympia, WA 98502 Claim No.: Job Title: Housekeeper – Assisted

Living DOT #: 323.687-014



Job Title: Housekeeper – Assisted Living DOT Title: Cleaner, Housekeeping SVP: 2 DOT #: 323.687-014 Wage: Type of Industry: 138 Any Industry



Brief Job Summary: Provide cleaning service to maintain clean rooms and common areas for assisted living residents. Worker will clean five residential units per day. Linens are changed by the Resident Service Associates (RSA) not Housekeeping.

Essential Job Functions: • Pick up trash from kitchen, dining room, public restroom and laundry.• Mop public restroom, laundry and kitchen.• Clean public restroom and check toilet paper, soap, toilet seat cover and paper towel.• Use broom and dust pan to clean carpet in dining room.• Vacuum rooms.• Assist with extra projects as assigned.

Training/Preparation Required: The ability to follow verbal instruction and perform routine work. Ability to read English for cleaning/chemical labels (writing not necessary). Must pass background check.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Vacuum, housekeeping cart, cleaning rags, mop bucket, cleaning supplies, gloves and respiratory mask for viral sanitizing.

Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Housekeeper – Assisted Living DOT Code: 323.687-014

Claimant: Claim No.: Job Title: Housekeeper – Assisted Living Body Part Injured: DOT Code: 323.687-014




Sitting X SELDOM sit. Standing X While performing daily job tasks up to two hours at a

time, up to eight hours total per day, interspersed with walking between rooms. Standing occurs on carpeted, wood and vinyl floors. Stand and walk combined are CONSTANT.

Walking X Walking between rooms performed intermittently with static standing throughout the work shift. Maximum distance walked at one time is 50 feet between rooms and residential units. Walking occurs on carpeted, wood, concrete and vinyl floors. Walk and stand combined are CONSTANT.


lbs.

Lift up to 5 pounds of cleaning supplies, dirty clothes, and garbage. 4-6 times per day lift up to 20 pounds for mop bucket of water and vacuum.

20 5


N S O F C

lbs.

From 1 to 20 pounds when moving full mop bucket. Carrying occurs between supply closets and the cart or to/from a room to the cart.

20 5



Push/pull vacuum, mop and broom. Push/pull housekeeping cart requiring 15 pounds force.

15 5


Perform Work on Ladders X Climb Stairs X Twisting X Twist at the waist while wiping down beds, cleaning tight

bathroom spaces and walls, vacuuming, and mopping.


Based on F252-072-000 12- 2015 Page 3 of 6


Job Demand Frequency Activity Description Stooping / Bending X Bending at the waist while performing cleaning

activities, special projects (i.e. wiping down patio furniture, removing chair marks on walls). Crouch/kneel/bend/stoop may be used interchangeably at employee’s discretion.

Squatting / Kneeling X Crouch/kneel/bend/stoop may be used interchangeably at employee’s discretion.


Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Majority of daily cleaning requirements – mopping,

vacuuming, cleaning mirrors and windows, sinks, tables and emptying garbage. Seldom reach below waist to clean areas close to floor or to pick up items. Bilateral reach is required.

Work Above Shoulders X Chest level to overhead: SELDOM for cleaning walls, kitchen cupboards, windows and dusting.

Keyboarding X Wrist Flexion/Extension X While performing some cleaning duties. Handle/Grasp X Light force when handling cleaning materials. Forceful Grasp X Forceful grasping is needed when vacuuming,

performing cleaning duties and moving housekeeping cart.

Fine Finger Manipulation X To perform job duties. Hand Controls X Operate finger and foot controls to turn the vacuum

on/off. Foot Controls X Operate finger and foot controls to turn the vacuum

on/off. Repetitive Motion X Body part: Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X Must be able to communicate with supervisors, co-workers and residents.

Hearing X Must be able to communicate with supervisors, co-workers and residents.

Tasting/Smelling X Must be able to discriminate smells for sanitary conditions.

Visual - Near Acuity X To verify cleanliness and navigate facility. Visual - Far Acuity X Navigate facility. Visual - Depth Perception X


Based on F252-072-000 12- 2015 Page 4 of 6



X




X



Exposure to Radiation X Other: Soiled items. X Noise Intensity 1 = Very Quiet, 2 = Quiet,





Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 5 of 6


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Housekeeper – Nursing Home

Brief Job Description/Duties: Provide cleaning service to maintain clean rooms and common areas in nursing home. Worker will clean up to 30 rooms per day.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. 20 lbs. lbs. 5 lbs. lbs. Carry lbs. 20 lbs. lbs. 5 lbs. lbs. Push / Pull lbs. 35 lbs. 15 lbs. 5 lbs. lbs.

Optional Comments:





Job Title: Housekeeper – Nursing Home DOT Code: 323.687-014




Olympia, WA 98502 Claim No.: Job Title: Housekeeper – Nursing

Home DOT #: 323.687-014



Job Title: Housekeeper – Nursing Home DOT Title: Cleaner, Housekeeping SVP: 2 DOT #: 323.687-014 Wage: Type of Industry: 138 Any Industry



Brief Job Summary: Provide cleaning service to maintain clean rooms and common areas in nursing home. Worker will clean up to 30 rooms per day.

Essential Job Functions: • Pick up trash, remove garbage from room.• Remove bed linens and place in laundry chute; replace with new clean linens.• Mop and clean bathroom mirrors, sink, toilet, shower and floors.• Vacuum resident room and entry way (janitor vacuums halls).• Clean inside windows as needed.• Provide wall washing and deep cleaning for viral infection decontamination.• Wipe down hydraulic bed frames as assigned.• Assist with extra projects as assigned.


Machine, Tools, Special Equipment, Personal Protective Equipment Used: Vacuum, housekeeping cart, linens, mop bucket, cleaning supplies, gloves, respiratory mask for viral sanitizing.

Based on F252-072-000 12- 2015 Page 2 of 7

Job Title: Housekeeper – Nursing Home DOT Code: 323.687-014

Claimant: Claim No.: Job Title: Housekeeper – Nursing Home Body Part Injured: DOT Code: 323.687-014




Sitting X SELDOM sit. Standing X While performing daily job tasks up to two hours at a

time, up to eight hours total per day, interspersed with walking between rooms. Standing occurs on carpeted, wood and vinyl floors. Stand and walk combined are CONSTANT.

Walking X Walking between rooms performed intermittently with static standing throughout the work shift. Maximum distance walked at one time is 50 feet between rooms and residential units. Walking occurs on carpeted, wood, concrete and vinyl floors. Walk and stand combined are CONSTANT.


lbs.

Lift up to 5 pounds of cleaning supplies, dirty clothes, and garbage. 4-6 times per day lift up to 20 pounds for mop bucket of water and vacuum.

20 5


N S O F C

lbs.

From 1 to 20 pounds when moving full mop bucket. Carrying occurs between supply closets and the cart or to/from a room to the cart.

20 5


N S O F C

lbs. of force

Push/pull vacuum, mop and broom. Push/pull housekeeping cart requiring 15 pounds force. SELDOM move bed frames with caster wheels requiring 35 pounds force.

35 15 5


Perform Work on Ladders X Climb Stairs X Twisting X Twist at the waist while wiping down beds, cleaning tight

bathroom spaces and walls, vacuuming, and mopping.



Job Demand Frequency Activity Description Stooping / Bending X Bending at the waist while performing cleaning






Work Above Shoulders X Chest level to overhead: SELDOM for cleaning walls and windows and dusting.





on/off. Repetitive Motion X Body part: Vibratory Tasks - Low X Exposure to upper extremity vibration when vacuuming. Vibratory Tasks - High X





Visual - Near Acuity X To verify cleanliness and navigate facility. Visual - Far Acuity X Navigate facility. Visual - Depth Perception X Visual - Color Discrimination

X



Job Demand Frequency Activity Description Visual - Accommodation X Visual - Field Of Vision X





X








Analyst:

6/26/16




Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 7 of 7





Job Title: Housekeeper - Retirement Community

Brief Job Description/Duties: Assist in maintaining and cleaning common areas in a senior retirement apartment community.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. 20 lbs. lbs. 5 lbs. lbs. Carry lbs. 20 lbs. lbs. 5 lbs. lbs. Push / Pull lbs. lbs. 15 lbs. 5 lbs. lbs.

Optional Comments:





Job Title: Housekeeper - Retirement DOT Code: 323.687-014




Olympia, WA 98502 Claim No.: Job Title: Housekeeper - Retirement

Community DOT #: 323.687-014



Job Title: Housekeeper - Retirement Community DOT Title: Cleaner, Housekeeping SVP: 2 DOT #: 323.687-014 Wage: Type of Industry: 138 Any Industry



Brief Job Summary: Assist in maintaining and cleaning common areas in a senior retirement apartment community.

Essential Job Functions: • Disinfect and clean community bathrooms in each building (sink, toilet, floors, mirrors).• Vacuum, sweep and/or mop all halls, community room, sun rooms, kitchens and lobby.• Dust and clean library, community areas, window sills, windows and stair wells.


Machine, Tools, Special Equipment, Personal Protective Equipment Used: Vacuum, housekeeping cart, mop and bucket, cleaning supplies and Motorola walkie/talkies.



Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Housekeeper - Retirement DOT Code: 323.687-014

Claimant: Claim No.: Job Title: Housekeeper - Retirement Body Part Injured: DOT Code: 323.687-014


Sitting X Seldom sit. Standing X Standing occurs intermittently with walking so

together these two demands occur on a CONSTANT basis. Standing tends to be dynamic, occurring in conjunction with movement in such a way as to involve frequent changes of position. Standing occurs over level surfaces within the establishment. Stand/walk on carpeted/linoleum/concrete floors.

Walking X Walking occurs intermittently with standing so together these two demands occur on a CONSTANT basis. Walking occurs over level surfaces within the establishment. Stand/walk on carpeted/linoleum/concrete floors.


lbs.

Cleaning supplies, garbage, mop bucket. The heaviest item lifted is the vacuum cleaner with attachments (approximately 20 pounds) and it is lifted 8” off the floor to the cleaning cart.

20 5


N S O F C

lbs.

From 1 to 20 pounds when moving full mop bucket. Carrying occurs for distances of up to 20 feet between supply closets and the cart or to/from a room to the cart.

20 5


N S O F C

lbs. of force

FREQUENTLY with variable force when cleaning, using the vacuum, moving patio furniture or moving the rolling cart. Push/pull force required for the cart is approximately 15 pounds and the maximum required of all job tasks.

15 5


Perform Work on Ladders X Climb Stairs X Twisting X Twist at waist when vacuuming, moping and cleaning. Stooping / Bending X Bending at the waist while performing cleaning








Work Above Shoulders X Chest level to overhead: SELDOM for cleaning walls and windows and dusting.





on/off. Repetitive Motion X Body part: Vibratory Tasks - Low X Vibratory Tasks - High X





Visual - Near Acuity X To verify cleanliness and navigate facility. Visual - Far Acuity X Navigate facility. Visual - Depth Perception X Visual - Color Discrimination

X






X








Analyst:

6/26/16




Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Kitchen Aid

Brief Job Description/Duties: Provides assistance in the kitchen area prior to, during and after meals are served to the residents. This position is primarily used to assist the kitchen and nursing staff in providing assistance wherever needed. Must be able to tolerate the fast pace of a busy kitchen.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. 20-50 lbs. 10-20 lbs. 10 lbs. lbs. Carry lbs. lbs. 10-20 lbs. 10 lbs. lbs. Push / Pull lbs. lbs. 15 lbs. lbs. lbs.

Optional Comments:





Job Title: Kitchen Aid DOT Code: 318.687-010




Olympia, WA 98502 Claim No.: Job Title: Kitchen Aid DOT #: 318.687-010



Job Title: Kitchen Aid DOT Title: Kitchen Helper SVP: 2 DOT #: 318.687-010 Wage: Type of Industry: 453, Hotel and Restaurant



Brief Job Summary: Provides assistance in the kitchen area prior to, during and after meals are served to the residents. This position is primarily used to assist the kitchen and nursing staff in providing assistance wherever needed. Must be able to tolerate the fast pace of a busy kitchen.

Essential Job Functions: • May be required to provide assistance to the nursing staff by passing water to residents within the facility.• May assist dishwasher following meal in scraping plates.• May assist prep cook in preparing deserts or snacks for residents.• May set up meal trays for residents according to special diets and personal requests.• May be required to note the amount of food consumed by the residents during the meal.• May be required to carry trays to residents who are ill.• May be required to clean tables in the dining area after each meal.

Training/Preparation Required: Job duties can be learned through short term on the job training. Ability to interact with residents.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Water pitcher, cooking/preparation utensils, trays, glasses, plates, etc.



Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Kitchen Aid DOT Code: 318.687-010

Claimant: Claim No.: Job Title: Kitchen Aid Body Part Injured: DOT Code: 318.687-010


Sitting X Standing X Frequent standing and walking up to two hours at a

time, up to eight hours total on surfaces including carpeting, linoleum and tile. Some floor surfaces may be wet when dish washing or from food dropped on the floor.

Walking X Frequent walking and standing up to two hours at a time, up to eight total on surfaces including carpeting, linoleum and tile. Some floor surfaces may be wet when dish washing or from food dropped on the floor.


lbs.

Frequent lifting up to 10 pounds when assisting dishwasher and emptying trays. Pull trays from tray rack which may contain plates, utensils and glassware. Occasional lifting 10 to 20 pounds (a stack of clean trays, etc). Seldom lift 5 gallon water jugs weighing up to 50 pounds.

20-50 10-20 10


N S O F C

lbs.

Carry food trays to ill residents in their room. Full trays may weigh 10 pounds. Occasionally carry a stack of clean trays to a holding area weighing from 10 to 20 pounds a distance of approximately 10 to 20 feet at one time. Not required to carry anything over 20 pounds.

10-20 10


N S O F C

lbs. of force

Occasional pushing during the course of a day when passing water pitchers and when pushing a cart holding the water pitchers. Cart rolls easily across tile surface.

15


Perform Work on Ladders X Climb Stairs X Twisting X Occasional twisting at waist when assisting dishwasher

or passing water pitchers to residents. Stooping / Bending X To perform various job duties. Squatting / Kneeling X Crawling X Balancing X


Based on F252-072-000 12- 2015 Page 3 of 6


Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X When passing water pitchers and when cleaning tables

in dining area after each meal. Occasional reaching below waist when assisting the dishwasher. Occasional repetitive arm and hand motion when scraping plates and loading trays for the dishwasher.

Work Above Shoulders X To perform various job duties. Keyboarding X Wrist Flexion/Extension X Handle/Grasp X Constant handling of various items such as food, plastic

water pitchers, plastic food trays, utensils and various sizes of glassware. Occasional repetitive arm and hand motion when scraping plates and loading trays for the dishwasher.

Forceful Grasp X To lift heavy items, scrape plates, etc. Fine Finger Manipulation X To perform various job duties. Hand Controls X Use of hand controls may be required to operate kitchen

equipment. Foot Controls X Repetitive Motion X Body part: Arm/Hand When scraping dishes. Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X Necessary for communicating with others and for taking instructions from others.

Hearing X Necessary for communicating with others and for taking instructions from others.

Tasting/Smelling X Visual - Near Acuity X Necessary for doing the job effectively and correctly. Visual - Far Acuity X Necessary for doing the job effectively and correctly. Visual - Depth Perception X Visual - Color Discrimination

X



N S O F C Exposure to Weather X Extreme Cold X Walk-in refrigerator. Extreme Hot X Ovens, dishwasher. Wet and / or Humidity X Kitchen floors, dishwasher.


Based on F252-072-000 12- 2015 Page 4 of 6



Proximity to Moving Mechanical Parts

X








Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 5 of 6


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Laundry Worker – Nursing Home

Brief Job Description/Duties: Worker maintains supply of clean linens, towels and clothes for use by residents and/or staff.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. lbs. 6-15 lbs. 3-5 lbs. 2 lbs. Carry lbs. lbs. 15 lbs. lbs. lbs. Push / Pull lbs. lbs. lbs. lbs. 10 lbs.

Optional Comments:





Job Title: Laundry Worker, Nursing Home DOT Code: 361.685-018




Olympia, WA 98502 Claim No.: Job Title: Laundry Worker – Nursing

Home DOT #: 361.685-018



Job Title: Laundry Worker – Nursing Home DOT Title: Laundry Worker II SVP: 2 DOT #: 361.685-018 Wage: Type of Industry: 138 Any Industry



Brief Job Summary: Worker maintains supply of clean linens, towels and clothes for use by residents and/or staff.

Essential Job Functions: • Retrieve laundry from laundry chutes using carts approximately 30"x67"x42" (1 cubic yard capacity).• Sort laundry into groups: sheets and gowns, blankets, bath blankets and soiled items. Each resident's

personal laundry arrives separately, is weighed and charged by the pound.• Load articles into commercial front load washers (opening approximately 32" off floor) and add specified

amount of detergent. Average of 30-40 loads of laundry each day.• Pull wet articles from washer to cart measuring with false bottom at 24" off floor.• Place wet articles into commercial front load dryers (opening center approximately 33" off floor).• Remove articles from dryer into cart and fold on counter at 36" height.• Place clean folded articles on portable wire storage racks with shelves at 12", 30", 48" and 60" off floor or

in appropriate storage bin.• May return storage racks to utility closets on resident floors for housekeeping and staff use.• May hang clothes on racks according to name and numbers.• May deliver all personal laundry to designated areas.• May ensure that all clothes are mended and ready to wear.• Specific jobs as assigned by supervisor.

Training/Preparation Required: One year of experience in a commercial establishment. Ability to meet the physical demands of the position. Basic English communication skills. No GED required.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Industrial front load washers and dryers, scale, wire racks, carts, various rolling baskets and bins and hangers.

Based on F252-072-000 12- 2015 Page 2 of 7

Job Title: Laundry Worker, Nursing Home DOT Code: 361.685-018

Claimant: Claim No.: Job Title: Laundry Worker, Nursing Home Body Part Injured: DOT Code: 361.685-018




Sitting X Standing X Dynamic standing while sorting and folding articles.

Static standing may occur up to 5 minutes uninterrupted while folding at the counter. Stand and walk are alternated regularly throughout the shift. Standing occurs on vinyl, non-skid painted concrete and industrial carpeted floors.

Walking X Walking up to 10 minutes when moving empty/full laundry racks to specified location throughout facility and when retrieving dirty laundry from laundry chutes. This is necessary approximately every 30 minutes and shared with other laundry staff. Walking occurs on vinyl, non-skid painted concrete and industrial carpeted floors.


lbs.

Floor to Waist Level: CONSTANT up to 2 pounds for individual articles. FREQUENT 3-5 pounds for wet linens and blankets. Waist to Shoulder Level: CONSTANT up to 2 pounds for individual articles. FREQUENT 3-5 pounds for stacks of clean linens, wet linens and blankets. OCCASIONAL 6- 15 pounds for stacks of larger linens. Shoulder Level to Overhead: OCCASIONAL up to 2 pounds for hanging resident laundry on racks.

6-15 3-5 2

Carry (Dist.) 5 ft.

N S O F C

lbs.

OCCASIONAL carry of ounces to 15 pounds up to 5 feet to place stacks of clean linens on storage racks. Various carts are available to move items around the facility and minimize necessary carrying.

15


N S O F C

lbs. of force

FREQUENTLY items are pulled from the washer and dryer requiring 3-4 pulls per load. Items are rolled directly into a cart and never carried.CONSTANT push/pull

10



Job Demand Frequency & Weight Activity Description laundry carts loaded with dirty linens from chutes, push/pull dirty resident laundry from scale and push/pull dirty linens from sorting bins. Push/pull will also be used to load and unload washer and dryer and to move hanging clothes racks and to move clean laundry to folding table. Push/pull force is typically less than 10 pounds. SELDOM push/pull of rolling storage shelving requires a push/pull force up to 30 pounds. Push/pull occurs on vinyl, non-skid painted concrete and industrial carpeted floors.


Perform Work on Ladders X Climb Stairs X Elevators are available. Twisting X Twisting at waist when loading and unloading washer

and dryer. Twisting may be minimized by re-positioning of the feet.

Stooping / Bending X Bending up to 45 degree angle when loading and unloading washers, dryers and baskets. Opening to dryers and washers is at approximate waist height, 32-33”.

Squatting / Kneeling X Required once a day to clean the lent traps in the dryers.


Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Waist to shoulder level: FREQUENT when retrieving

items from dryer (drum is 50” deep) and washer and when folding articles of clothing/linens. FREQUENT reach to remove dirty clothes from laundry chute and to place clean items on shelves. Floor to waist level: OCCASIONAL when retrieving items from sorting carts and residents’ personal items from scale. As needed for dropped articles.

Work Above Shoulders X Shoulder level to overhead: SELDOM when hanging clothes on hanging racks and placing linens on upper shelves.

Keyboarding X Wrist Flexion/Extension X Handle/Grasp X CONSTANT handling and grasping of linens and

clothes, both wet and dry.



Job Demand Frequency Activity Description Forceful Grasp X Grasping of carts and storage rack as needed requiring

a stronger grasp. Fine Finger Manipulation X FREQUENT fine finger manipulation while folding linens

and personal items belonging to residents. Hand Controls X FREQUENTLY operate the hand controls on the

washers/dryers (push button, knobs, dial turn, etc.) Foot Controls X Repetitive Motion X Body part: Arms/Hands Repetitively reach and grasp

to perform job duties. Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X Talking/hearing is needed to communicate with others and when taking instructions. Basic English is okay.

Hearing X Talking/hearing is needed to communicate with others and when taking instructions. Basic English is okay.

Tasting/Smelling X Smell is needed to detect odors and soiled articles. Taste is not a requirement of this position.

Visual - Near Acuity X Must be able to detect cleanliness and to read labels. Visual - Far Acuity X To navigate facility. Visual - Depth Perception X Visual - Color Discrimination

X



N S O F C Exposure to Weather X Extreme Cold X Extreme Hot X In laundry area. Wet and / or Humidity X In laundry area. Proximity to Moving Mechanical Parts

X



Exposure to Radiation X Other: Soiled items. X





3




Analyst:

6/26/16




Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 7 of 7





Job Title: Licensed Practical Nurse (LPN) -Wellness Nurse – Assisted Living

Brief Job Description/Duties: Assists RN Wellness Nurse in providing education counseling and appropriate nursing services that assist village residents in living their lives.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X X Lift lbs. 25-50 lbs. 10-25 lbs. 10 lbs. lbs. Carry lbs. lbs. 10 lbs. 5 lbs. lbs. Push / Pull lbs. 25-35 lbs. 10 lbs. lbs. lbs.

Optional Comments:





Job Title: LPN - Assisted Living DOT Code: 079.374-014




Olympia, WA 98502 Claim No.: Job Title: Licensed Practical Nurse

(LPN) -Wellness Nurse – Assisted Living

DOT #: 079.374-014 Phone: 360-993-5723 Involved body parts:


Job Title: Licensed Practical Nurse (LPN) -Wellness Nurse – Assisted Living

DOT Title: Nurse, Licensed Practical

SVP: 6 DOT #: 079.374-014 Wage: Type of Industry: 573 Medical Services



Brief Job Summary: Assists RN Wellness Nurse in providing education counseling and appropriate nursing services that assist village residents in living their lives.

Essential Job Functions: • Checks RSA (Resident Service Associate) Logs daily and coordinates 24 hour report.• Provides or delegates, as appropriate, direct nursing services, treatment and assistance to residents.• Works closely with the RN Wellness Nurse to provide staff development (RSA initial and ongoing training)

and supervision.• Under the direction of the RN Wellness Nurse, completes the resident assessments prior to resident move

in, 30 days after resident move in, semiannually and when there is a change in condition.• Coordinates and schedules individual Resident Service Plan with each resident, his/her family and staff

(30 day and semiannual).• Notifies family of recommended service package changes resulting from change in condition.• Visits each resident quarterly and updates assessment if appropriate.• Under the direction of the RN Wellness Nurse, executes the Quality Assurance Program.• May provide shopping for residents.• May assist with payroll and monthly resident billing.• Performs other duties as assigned by management to meet changing job-related requirements.

Training/Preparation Required: Current Washington State LPN License with current necessary training under Washington State WAC regulations. High School diploma and three years of college or comparable education. One year experience.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Blood pressure cuff, thermometer, stethoscope, gloves, telephone, transfer belt, computer and medical equipment/supplies. Based on F252-072-000 12- 2015 Page 2 of 7

Job Title: LPN - Assisted Living DOT Code: 079.374-014

Claimant: Claim No.: Job Title: LPN - Assisted Living Body Part Injured: DOT Code: 079.374-014




Sitting X While charting activities and medical information by computer and/or hand and communicating with families.

Standing X Intermittent with walking while making rounds and checking on residents. Floor surfaces are generally carpet, linoleum, tile or concrete.

Walking X Intermittent with standing while making rounds and checking on residents. Floor surfaces are generally carpet, linoleum, tile or concrete.


lbs.

FREQUENT lift of 0-10 pounds for resident files and individual medical supplies. Lifting up to 25 pounds required when stocking medical supplies. Lifting up to 50 pounds is rarely (1-2 time per month) required to assist or transfer residents. The correct use of a transfer belt is required to avoid injury to the resident or nurse. Lifting is performed from floor to shoulder level. Lifting over shoulder level is SELDOM.

25-50 10-25 10

Carry (Dist.) ft.

N S O F C

lbs.

FREQUENT up to 5 ponds. OCCASIONAL up to 10 pounds when carrying resident treatment bag or other items. Carts are used for moving items weighing more than 10 pounds, such as medical equipment and supplies.

10 5


N S O F C

lbs. of force

OCCASIONAL push/pull cart with medical equipment and supplies requiring up to 10 pounds of force. SELDOM push/pull cart loaded with heavier supplies requiring push/pull force up to 25 pounds. Typically cart rolls easily over concrete walkways, carpeting and tile. Push wheelchairs on a SELDOM

25-35 10


Based on F252-072-000 12- 2015 Page 3 of 7


Job Demand Frequency & Weight Activity Description basis. In regards to pushing wheelchairs the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. CPR is performed on a SELDOM basis - on average 2-4 times per year. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives – typically 1-4 minutes.


Perform Work on Ladders X Climb Stairs X Twisting X OCCASIONAL twisting at the waist may occur when

providing medical treatments, assisting in transfer or when applying/changing daily bandages and leg wraps.

Stooping / Bending X Bending required when providing treatment to residents, administering medications, taking vital signs and assisting seated residents. Must be able to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee’s discretion.

Squatting / Kneeling X On a rare basis may need to kneel or crouch to retrieve items at floor level. Must be able to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee’s discretion.

Crawling X Balancing X Must be able to balance when assisting residents with

movement, employee does not work at heights.

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Reaching FREQUENTLY at all levels from standing and

seated positions up to full arm extension when administering to residents who are bedridden and seated, reaching for supplies and using phone, charting information.

Work Above Shoulders X When reaching for medical records, dishes and supplies located on shelves.

Keyboarding X To access and document information.


Based on F252-072-000 12- 2015 Page 4 of 7


Job Demand Frequency Activity Description Wrist Flexion/Extension X While keyboarding. Handle/Grasp X FREQUENT grasping when handling pens/pencils for

documenting information into medical charts, when handling paperwork and while using various medical supplies/equipment (stethoscope, thermometer, medications, syringes, etc.).

Forceful Grasp X Forceful grasp used when pushing resident in wheelchair and performing some nursing duties.

Fine Finger Manipulation X OCCASIONAL fine finger manipulation while using the computer and telephone and when performing first aid and administering shots.

Hand Controls X OCCASIONAL intermittent use of various hand controls with knobs to turn, buttons to push and switches to flip as needed for blood pressure cuff and various other medical equipment.

Foot Controls X The use of foot controls is SELDOM. Repetitive Motion X Body part: Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X Necessary for communicating with others, safety awareness and for taking instructions from physicians and supervisor. Must be able to communicate in English.

Hearing X Necessary for communicating with others, safety awareness and for taking instructions from physicians and supervisor. Must be able to communicate in English.

Tasting/Smelling X Smell is required and necessary to detect dangerous odors when providing wound treatment and performing health assessment

Visual - Near Acuity X CONSTANT for doing job effectively and correctly. Visual - Far Acuity X To navigate facility. Visual - Depth Perception X To perform various job duties Visual - Color Discrimination

X To perform various job duties

Visual - Accommodation X To perform various job duties Visual - Field Of Vision X CONSTANT for doing job effectively and correctly.


N S O F C Exposure to Weather X Extreme Cold X


Based on F252-072-000 12- 2015 Page 5 of 7



Extreme Hot X Wet and / or Humidity X Proximity to Moving Mechanical Parts

X


X Will be exposed to household chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry.






Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 6 of 7


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 7 of 7





Job Title: Licensed Practical Nurse (LPN), Primary Care - Nursing Home

Brief Job Description/Duties: The LPN will direct, administer and record the care given to residents in an assigned section of the nursing facility.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X X Lift lbs. 250 lbs. 10-25 lbs. 10 lbs. lbs. Carry lbs. lbs. 10 lbs. 5 lbs. lbs. Push / Pull lbs. 35 lbs. 25 lbs. 10 lbs. lbs.

Optional Comments:





Job Title: LPN - Nursing Home DOT Code: 079.374-014




Olympia, WA 98502 Claim No.: Job Title: Licensed Practical Nurse

(LPN), Primary Care - Nursing Home



Job Title: Licensed Practical Nurse (LPN), Primary Care - Nursing Home

DOT Title: Nurse, Licensed Practical




Brief Job Summary: The LPN will direct, administer and record the care given to residents in an assigned section of the nursing facility.

Essential Job Functions: • Documentating and directing the other nursing staff in performing care for the resident.• Communicate with family members regarding the progress of the resident.• Assist visiting physicians in rounds.• Draw blood and obtain fluids to submit for lab work.• May be required to complete intravenous infusion/injection.• Record and issue appropriate medications.• May be required to work with Alzheimer's residents who are not cooperative.• Record and monitor all progress of residents and communicate with physicians.• May be required to assist in passing out trays to residents in dining area and assist in feeding.• Monitor work of other nursing staff in unit to ensure thoroughness.• Required to use telephones to communicate with physicians, arrange for transportation for doctor

appointments and contact families.• Make rounds to ensure cleanliness and proper care to residents.• Coordinate care of residents.• Manages all NAC staff in section.• Assists staff members according to needs.• Follow set protocol in emergency situation.

Training/Preparation Required: Current Washington State LPN License with current necessary training under Washington State WAC regulations. High School diploma and three years of college or comparable education. One year experience.

Based on F252-072-000 12- 2015 Page 2 of 8

Job Title: LPN - Nursing Home DOT Code: 079.374-014

Claimant: Claim No.: Job Title: LPN - Nursing Home Body Part Injured: DOT Code: 079.374-014

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Computer, telephone, gowns, goggles, gloves, masks, Accucheck (Blood Sugar), scale, blood pressure cuff, bladder scanner, pulse oximeter, thermometer, oxygen concentration, IV pumps, portable oxygen and various first aid supplies and equipment.




Sitting X OCCASIONAL while charting activities and medical information by computer and/or hand, when phoning doctors, taking orders and communicating with families.

Standing X OCCASIONAL standing intermittent with walking is performed for up to two hours at a time while making rounds and checking on residents. Employer states static stand up to 2 minutes at one time when administering treatments. Twice per week static standing is required up to 45 minutes for longer treatments. Floor surfaces are generally carpet, linoleum, tile or concrete.

Walking X FREQUENT walking intermittent with standing. Floor surfaces are generally carpet, linoleum, tile or concrete.


lbs.

FREQUENT lift up to 10 pounds for resident files and supplies. Lifting 10-25 pounds OCCASIONALLY required for medical supplies/equipment. SELDOM lifting up to 50 pounds to assist and transfer residents with transfer belt. The correct use of a transfer belt is required to avoid injury to the resident or nurse. Vera Lift and Vander Lifts are used to minimize weight. Lifting primarily performed from floor to shoulder level. Lifting over shoulder level is SELDOM.

250 10-25 10

Carry (Dist.) ft.

N S O F C lbs.

FREQUENT up to 5 pounds. OCCASIONAL 5-10 pounds to move 10 5


Based on F252-072-000 12- 2015 Page 3 of 8


Job Demand Frequency & Weight Activity Description items from one location in the facility to another. Carts are available for heavier supplies and/or equipment.


N S O F C

lbs. of force

FREQUENT push/pull cart with medical equipment and supplies requiring up to 10 pounds of force. SELDOM push/pull cart loaded with heavier supplies requiring push/pull force up to 25 pounds. Typically cart rolls easily over concrete walkways, carpeting and tile. Push wheelchairs on an OCCASIONAL basis. In regards to pushing wheelchairs the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. Each employee performs CPR on a SELDOM basis. CPR is needed 1-2 times per week throughout the facility and multiple employees perform this function. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives – typically 1-4 minutes.

35 25 10


Perform Work on Ladders X Climb Stairs X Twisting X OCCASIONAL twisting may occur while providing

patient care. Stooping / Bending X OCCASSIONAL bending may occur when providing

treatment to residents, administering medications, taking vital signs and assisting seated residents, etc. Must be able to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee’s discretion.


Crawling X


Based on F252-072-000 12- 2015 Page 4 of 8


Job Demand Frequency Activity Description Balancing X Must be able to balance when assisting residents with




Work Above Shoulders X Above shoulder level – OCCASIONAL when attending patients with tubes and IVs and to obtain supplies on shelves.

Keyboarding X To access and document information. Wrist Flexion/Extension X While keyboarding. Handle/Grasp X FREQUENT handling paperwork, pens/pencils,

telephone and various medical supplies/equipment (i.e. stethoscope, thermometer, medications, syringes, etc).


Fine Finger Manipulation X OCCASIONAL fine finger manipulation while using the computer keyboard, writing, and when performing first aid, administering shots and medications.

Hand Controls X FREQUENT use of various hand controls with knobs to turn, buttons to push and switches to flip as needed for blood pressure cuff and various other medical equipment.

Foot Controls X The use of foot controls may be required for hydraulic beds, wheelchair brakes, etc.



Talking X Necessary for safety awareness and for communicating and taking instructions from physicians, labs, pharmacists, families and supervisor. Ability to read, write, and speak English.

Hearing X Necessary for safety awareness and for communicating and taking instructions from physicians, labs, pharmacists, families and supervisor. Ability to read, write, and speak English.

Tasting/Smelling X Smell is required and necessary to detect dangerous odors, provide wound treatment and to perform health assessment/diagnosis.


Based on F252-072-000 12- 2015 Page 5 of 8


Job Demand Frequency Activity Description Visual - Near Acuity X Must be able to read labels, doctor’s instructions,

medication orders, charts and medical history. Visual - Far Acuity X To navigate facility. Visual - Depth Perception X To perform various job duties. Visual - Color Discrimination

X To perform various job duties.

Visual - Accommodation X To perform various job duties. Visual - Field Of Vision X CONSTANT for doing job effectively and correctly.



X


X Will be exposed to household and hospital chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry. May use mask, goggles and gowns. Possible exposure to needle pricks.







Based on F252-072-000 12- 2015 Page 6 of 8


Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 7 of 8


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 8 of 8





Job Title: Maintenance

Brief Job Description/Duties: Repair and maintain physical structure of senior housing community consisting of 300 plus residential units, common areas and facilities.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. lbs. 10-50 lbs. 10 lbs. lbs. Carry lbs. 25-50 lbs. 25 lbs. lbs. 5 lbs. Push / Pull lbs. lbs. 25 lbs. lbs. 5 lbs.

Optional Comments:





Job Title: Maintenance DOT Code: 899.381-010




Olympia, WA 98502 Claim No.: Job Title: Maintenance DOT #: 899.381-010



Job Title: Maintenance DOT Title: Maintenance Repairer, Building

SVP: 7 DOT #: 899.381-010 Wage: Type of Industry: 138 Any Industry



Brief Job Summary: Repair and maintain physical structure of senior housing community consisting of 300 plus residential units, common areas and facilities.

Essential Job Functions: • General maintenance may require plumbing repairs such as unclogging hair traps, unpluging toilets and

repair washer/dryers, refrigerators and stoves. • May be required to maintain and replace electrical outlets, and light bulbs.• May be required to remove furniture and clothing from rooms no longer occupied.• May be required to paint interior or exterior of facility.• May be required to install and check batteries of smoke alarms. May be required to assist Fire Marshall

with inspections.• May be required to maintain the grounds of the facility.• May assist in holiday decoration installation and removal.

Training/Preparation Required: Two plus years experience in maintenance and repair; well rounded knowledge of electrical, plumbing and appliances; acceptable background check. High school diploma/GED required.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Various power tools and hand tools and electrical and plumbing supplies. Hand truck, dolly and carts. May be required to operate a vehicle.

Based on F252-072-000 12- 2015 Page 2 of 8

Job Title: Maintenance DOT Code: 899.381-010

Claimant: Claim No.: Job Title: Maintenance Body Part Injured: DOT Code: 899.381-010




Sitting X Rarely to perform repairs or while driving. Standing X Occasional static standing is performed up to 15

minutes at a time on varying surfaces such as carpet, linoleum, tile, concrete, gravel, dirt, and grass. Standing is intermittent with walking and combined occur on a frequent basis.

Walking X Walking is frequent and alternated with static standing. Walking on various surfaces such as carpet, linoleum, tile, concrete, dirt and grass to move around the facility, work area and maintenance room.


lbs.

FREQUENT lift up to 10 pounds for tools and supplies. OCCASIONAL lift 10 to 25 pounds (cans of paint and various other equipment and supplies). OCCASIONAL lifting up to 50 pounds when lifting various supplies or equipment. Assistance is available in moving furniture that weighs over 50 pounds, so that the worker will not be lifting over 50 pounds as part of the shared weight. Hand truck, dolly and carts are available to move heavier items.

10-50 10


N S O F C

lbs.

Wear a tool belt containing tools weighing up to 15 pounds. OCCASIONAL carry up to 25 pounds of various supplies including cans of paint, tool box, equipment and supplies. SELDOM carry between 25 and 50 pounds when moving a case of paper, furniture and other items out of vacated apartments. The distance items are carried may be from 50 to 100 feet. Elevators are available if items need to be moved to another floor. For items

25-50 25 5


Based on F252-072-000 12- 2015 Page 3 of 8


Job Demand Frequency & Weight Activity Description weighing over 50 pounds there is assistance available or a hand truck/dolly can be used.



OCCASIONAL pushing/pulling when moving furniture. Carts available for moving heavier equipment.

25 5


Perform Work on Ladders X Climb ladders when decorating, painting or performing other job duties.

Climb Stairs X Elevators are available along with stairs for emergency situations or at employee’s discretion.

Twisting X OCCASIONAL twisting may occur at waist when performing carpentry work or working in tight spaces when repairing appliances. SELDOM twist at neck level when driving.

Stooping / Bending X FREQUENT bending occurs when repairing pipes under sinks, installing wall outlets, painting, assisting residents, and completing various work orders.

Squatting / Kneeling X OCCASIONAL crouching occurs when repairing pipes under sinks, installing wall outlets, painting and completing other work orders.

Crawling X SELDOM crawling when working under appliances and in tight spaces.

Balancing X Balance is needed when working on the ladder.

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X FREQUENT reaching between shoulder and waist

height when painting or performing tasks required for maintenance.

Work Above Shoulders X FREQUENT reaching above shoulder height when changing light bulbs, painting walls or ceiling and when climbing ladders. FREQUENT reaching below waist height when performing maintenance tasks on toilets and sinks, performing electrical testing and to obtain supplies.

Keyboarding X To access and document information. Wrist Flexion/Extension X To perform some job duties. Handle/Grasp X CONSTANT handling of various tools and supplies

during daily job tasks. Forceful Grasp X Forceful grasp is intermittent when using hand tools,

moving furniture and performing repairs. Fine Finger Manipulation X OCCASIONAL fine finger manipulation while working on

wiring, manipulating small parts for repairs and/or to complete projects and paperwork.


Based on F252-072-000 12- 2015 Page 4 of 8


Job Demand Frequency Activity Description Hand Controls X OCCASIONALLY operate hand and foot controls when

using vehicles, power tools or testing equipment. Foot Controls X OCCASIONALLY operate hand and foot controls when

using vehicles, power tools or testing equipment. Repetitive Motion X Body part: Hands/Arms For various job duties. Vibratory Tasks - Low X May be some whole body vibration when operating

equipment. Vibratory Tasks - High X


Talking X Necessary for communicating and taking instruction from others.

Hearing X Necessary for communicating and taking instruction from others.

Tasting/Smelling X Smell required when evaluating electrical and plumbing repair needs. Taste not a requirement for this position.

Visual - Near Acuity X Necessary for doing the job effectively and correctly. Visual - Far Acuity X While driving or performing various repairs. Visual - Depth Perception X While driving or performing various repairs. Visual - Color Discrimination

X When working with wiring or performing other tasks.

Visual - Accommodation X Visual - Field Of Vision X When driving and performing a variety of other tasks.


N S O F C Exposure to Weather X 20% is performed outdoors Extreme Cold X Extreme Hot X Wet and / or Humidity X During inclement weather. Proximity to Moving Mechanical Parts

X When working with some equipment.

Exposure to Explosives X Atmospheric Conditions X Exposed Heights X When working on a ladder. Exposure to Electricity X When performing electrical repairs. Exposure to Toxic / Caustic Chemicals

X Exposure to paint, paint thinner and other maintenance chemicals may occur. May be exposed to some infectious diseases and cleaning agents.




Based on F252-072-000 12- 2015 Page 5 of 8



Based on F252-072-000 12- 2015 Page 6 of 8





Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 7 of 8


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 8 of 8





Job Title: Medical Records Clerk

Brief Job Description/Duties: Compiles, verifies, types, and files medical records of health care facility.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X X Lift lbs. 30 lbs. lbs. 10 lbs. lbs. Carry lbs. lbs. 10 lbs. lbs. lbs. Push / Pull lbs. 10 lbs. lbs. lbs. lbs.

Optional Comments:





Job Title: Medical Records Clerk DOT Code: 245.362-010




Olympia, WA 98502 Claim No.: Job Title: Medical Records Clerk DOT #: 245.362-010



Job Title: Medical Records Clerk DOT Title: Medical-Record Clerk SVP: 4 DOT #: 245.362-010 Wage: Type of Industry: 573, Medical Service



Brief Job Summary: Compiles, verifies, types, and files medical records of health care facility.

Essential Job Functions: • Responsible for medical records information on each individual resident and incorporating the nursing staff

information into these records. • Process computerized resident plan of care and multidisciplinary flowsheets, updating, printing and

distributing care plan flowsheets and problem sheets. • Review charts of discharged residents for deficiencies and monitore to ensure compliance for correction of

deficient documentation. • Coordinate and fill in chronological order each section of the residents record.• May be required to send charts.• Maintain effective communication with others, both inside and outside the department to give or obtain

needed information or coordinate activities of residents.

Training/Preparation Required: Over 3 months, up to 6 months.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Computer and telephone.

Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Medical Records Clerk DOT Code: 245.362-010

Claimant: Claim No.: Job Title: Medical Records Clerk Body Part Injured: DOT Code: 245.362-010




Sitting X Frequent sitting at a desk and computer to input and update information.

Standing X Occasional standing and walking is performed on a variety of floor surfaces including carpeting, linoleum and tile.

Walking X Occasional walking and standing is performed on a variety of floor surfaces including carpeting, linoleum and tile.


lbs.

Lift up to 10 pounds of files, charts, office materials and supplies. Lift a box of records and supplies up to 30 pounds.

30 10


N S O F C

lbs.

Occasionally carry resident charts from one location to another a distance of 100 feet, depending upon the facility size. When transferring several charts a rolling cart can be utilized.

10


N S O F C

lbs. of force

Rare pushing/pulling when opening and closing desk drawers or moving a cart filled with medical records from one location to another.

10


Perform Work on Ladders X Climb Stairs X Twisting X Stooping / Bending X Occasional bending/stooping when retrieving charts or

supplies from lower shelves. Squatting / Kneeling X Crawling X Balancing X


Based on F252-072-000 12- 2015 Page 3 of 6


Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Reach between shoulder and waist height when

documenting information and compiling paperwork. Occasional reaching below waist while retrieving resident charts from lower shelves.

Work Above Shoulders X Reach above shoulder height when retrieving medical charts from upper shelves. Reach below waist while retrieving resident charts from lower shelves.

Keyboarding X To record and process information. Wrist Flexion/Extension X While keyboarding. Handle/Grasp X Handle medical charts, office supplies. Forceful Grasp X To lift items. Fine Finger Manipulation X Fingering when keyboarding. Hand Controls X Intermittent use of hand controls on the computer and

the telephone. Foot Controls X Repetitive Motion X Body part: Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X Necessary for communicating and taking instruction from doctors and supervisor.

Hearing X Necessary for communicating and taking instruction from doctors and supervisor.

Tasting/Smelling X Taste and Smell are not requirements for this position. Visual - Near Acuity X Necessary for doing the job effectively and correctly. Visual - Far Acuity X Visual - Depth Perception X Visual - Color Discrimination

X




X

Exposure to Explosives X


Based on F252-072-000 12- 2015 Page 4 of 6



Atmospheric Conditions X Exposed Heights X Exposure to Electricity X Exposure to Toxic / Caustic Chemicals







Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 5 of 6


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Nurse Assistant Certified (NAC) - Nursing Home

Brief Job Description/Duties: Provide direct care to nursing home residents, primarily for their activities of daily living but also to include some nursing care.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. 21-50 lbs. 11-20 lbs. 5-10 lbs. 5 lbs. Carry lbs. lbs. 15 lbs. 5 lbs. lbs. Push / Pull lbs. 35 lbs. 25 lbs. 10 lbs. lbs.

Optional Comments:





Job Title: NAC - Nursing Home DOT Code: 355.674-014




Olympia, WA 98502 Claim No.: Job Title: Nurse Assistant Certified

(NAC) - Nursing Home DOT #: 355.674-014



Job Title: Nurse Assistant Certified (NAC) - Nursing Home

DOT Title: Nurse Assistant




Brief Job Summary: Provide direct care to nursing home residents, primarily for their activities of daily living but also to include some nursing care.

Essential Job Functions: • Assist residents in and out of bed and into wheelchair with the correct use of the transfer belt (may require

the assistance of another aid depending on weight and physical/cognitive abilities of resident). • Assist residents in bathing.• Assist residents in dressing and undressing.• Assist residents in using bathroom facilities and peri care.• May be required to assist in personal grooming of residents (i.e. brush hair, trim finger nails and toe nails).• Take vital signs of residents (i.e. temperature and blood pressure) and record information.• Assist residents to dining area for meals. May be required to assist in feeding residents and documenting

intake of nourishment.• May strip bedding and replace with clean linens.• If resident is bedridden due to illness, aid may be required to turn resident intermittently.• May be required to clean bedpans and empty catheter bags.• Required to document information regarding the each resident's health, input/output and any change of

medical condition.• Must be able to perform CPR.

Training/Preparation Required: Nurse Assistant Certification and associated credentials necessary to work in a nursing home. High school diploma/GED required. Must be able to pass background check.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Blood pressure cuff, medical supplies, Vera Lift and Vander Lift and bathing chairs.

Based on F252-072-000 12- 2015 Page 2 of 8

Job Title: NAC - Nursing Home DOT Code: 355.674-014

Claimant: Claim No.: Job Title: NAC - Nursing Home Body Part Injured: DOT Code: 355.674-014




Sitting X OCCASIONAL sitting for periods up to 10-15 minutes at a time while feeding residents, visiting with residents and charting. Sitting typically does not occur more than one hour total each shift.

Standing X FREQUENT standing throughout the work day. Static standing occurs for periods up to 5 minutes at one time. Dynamic standing occurs for periods up to 15 minutes. Floor surfaces are generally carpet, linoleum, tile or concrete. Static and dynamic standing combined with walking occur CONSTANTLY throughout the work day. Standing positions are alternated on a frequent basis.

Walking X FREQUENT walking in assigned work area on carpeted, linoleum and tile floors. Walk combined with dynamic and static stand occur CONSTANTLY.


lbs.

CONSTANT - up to 5 pounds of residents’ personal items (i.e. clothing, food items, medical charts, notebooks, linens and supplies). FREQUENT – 5 to 10 pounds of supplies and equipment. OCCASIONAL - up to 50 pounds when lifting heavier equipment and when transferring a resident or when assisting a resident in bathing or dressing. Employer states typically two aids are utilized when resident is unusually heavy or combative.

21-50 11-20 5-10 5

Carry (Dist.) ft.

N S O F C

lbs.

FREQUENTLY carry up to 5 pounds of a residents’ personal items (i.e., clothing, food items, medical charts). OCCASIONALLY carry 15 pounds (trays, linens and medical equipment). Carts are used to move items weighing more than 15 pounds.

15 5


Based on F252-072-000 12- 2015 Page 3 of 8


Job Demand Frequency & Weight Activity Description Pushing/ Pulling (Dist.) ft.

N S O F C

lbs. of force

FREQUENT push/pull empty Vander-Lift and Vera-Lift to individual rooms as needed. FREQUENT push/pull cart with medical equipment and supplies requiring up to 10 pounds of force. SELDOM push/pull cart loaded with heavier supplies requiring push/pull force up to 25 pounds. Typically cart rolls easily over concrete walkways, carpeting and tile. Push wheelchairs on a OCCASIONAL basis. In regards to pushing wheelchairs the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. Each employee performs CPR on a SELDOM basis. CPR is needed 1-2 times per week throughout the facility and multiple employees perform this function. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives – typically 1-4 minutes.

35 25 10


Perform Work on Ladders X Climb Stairs X Twisting X OCCASIONAL twisting may occur at the waist while

transferring residents and performing other duties. Stooping / Bending X OCCASIONAL bending occurs while taking vital signs,

assisting residents in bathing, providing peri care, making beds, etc. Must be able to perform CPR.

Squatting / Kneeling X OCCASIONAL crouching/squatting may occur while bathing a resident. On a rare basis, may need to kneel or crouch to retrieve items at floor level or to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee’s discretion.


movement. Employee does not work at heights.


Based on F252-072-000 12- 2015 Page 4 of 8


Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Waist to shoulder level – FREQUENT when assisting

residents in eating, changing bed linens, taking vital signs. Below waist level – FREQUENT assisting residents with peri-care and bathing. As needed for reaching items located on lower shelves.

Work Above Shoulders X SELDOM when reaching for medical records or supplies located on shelves.

Keyboarding X To access/document information. Wrist Flexion/Extension X While keyboarding. Handle/Grasp X Employee will constantly grasp and handle grooming

implements, blood pressure cuff, thermometer, clothing, medications and other related items. Handle/grasp activities are non-repetitive and intermittent.

Forceful Grasp X To perform various job duties. Fine Finger Manipulation X OCCASIONAL fine finger manipulation occurs while

documenting residents’ medical charts and as needed for buttons and laces when dressing. Also used for operating blood pressure cuff and other medical equipment.

Hand Controls X OCCASIONALLY use blood pressure gauge and thermometer, office equipment and other nursing/medical equipment. The use of both hand and foot controls is required (i.e. wheelchair brakes, hydraulic beds, etc).

Foot Controls X OCCASIONALLY use blood pressure gauge and thermometer, office equipment and other nursing/medical equipment. The use of both hand and foot controls is required (i.e. wheelchair brakes, hydraulic beds, etc).



Talking X The ability to speak and hear is necessary for communicating with residents and other aids and for taking instructions from Charge Nurse and requests from residents.

Hearing X The ability to speak and hear is necessary for communicating with residents and other aids and for taking instructions from Charge Nurse and requests from residents.

Tasting/Smelling X Must be able to detect emergencies and determine the cleanliness of residents.

Visual - Near Acuity X Employee must have good vision to perform job tasks.


Based on F252-072-000 12- 2015 Page 5 of 8


Job Demand Frequency Activity Description Visual - Far Acuity X Employee must have good vision to perform job tasks. Visual - Depth Perception X To perform various job duties. Visual - Color Discrimination


Visual - Accommodation X To perform various job duties. Visual - Field Of Vision X To perform various job duties.



X


X Will be exposed to household and hospital chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry. May use mask, goggles and gowns.


2

Analyst’s Comments: Possible Employer Modifications:

Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a “best estimate” may have been used. Analyst:

6/26/16

Janet Snyder, B.A., CDMS Date Strategic Consulting Services, Inc.

Based on F252-072-000 12- 2015 Page 6 of 8



Based on F252-072-000 12- 2015 Page 7 of 8


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 8 of 8





Job Title: Nurse Manager

Brief Job Description/Duties: Responsible for assessment, planning, coordination, implementation and evaluation of elderly and/or end of life patients. Manage floor staff, complete scheduling, hiring, interviewing and counseling. Deal with physicians, hospice groups, the State, care plans and plans of correction. This is an administrative role with very little direct patient care. Population of patients is predominantly elderly - both transitional and long term care provided.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. lbs. 5 lbs. lbs. lbs. Carry lbs. lbs. 5 lbs. lbs. lbs. Push / Pull lbs. 5 lbs. lbs. lbs. lbs.

Optional Comments:





Job Title: Nurse Manager DOT Code: 075.127-014




Olympia, WA 98502 Claim No.: Job Title: Nurse Manager DOT #: 075.127-014



Job Title: Nurse Manager DOT Title: Nurse Consultant SVP: 7 DOT #: 075.127-014 Wage: Type of Industry: Medical Services



Brief Job Summary: Responsible for assessment, planning, coordination, implementation and evaluation of elderly and/or end of life patients. Manage floor staff, complete scheduling, hiring, interviewing and counseling. Deal with physicians, hospice groups, the State, care plans and plans of correction. This is an administrative role with very little direct patient care. Population of patients is predominantly elderly - both transitional and long term care provided.

Essential Job Functions: • Assess, plan, coordinate, implement and evaluate elderly and/or end of life patients.• Manage floor staff, complete scheduling, hiring, interviewing and counseling.• Deal with physicians, hospice groups, the State, care plans and plans of correction.

Training/Preparation Required: RN or LPN with current, valid state license. Supervisor/Manager experience is required. Must pass background check.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Telephone, laptop, printer, keyboard, mouse, printer, copier and other office equipment. Some nursing equipment and supplies.



Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Nurse Manager DOT Code: 075.127-014

Claimant: Claim No.: Job Title: Nurse Manager Body Part Injured: DOT Code: 075.127-014


Sitting X Sitting, standing and walking are alternated. Standing X Standing, sitting and walking are alternated. Walking X Walking, sitting and standing are alternated.


lbs.

Office supplies and nursing supplies.

5

Carry (Dist.) ft.

N S O F C lbs.

Office supplies and nursing supplies

5



To open/close drawers, to perform clinical assessment, and to move equipment.

5


Perform Work on Ladders X Climb Stairs X Twisting X Stooping / Bending X To reach supplies or perform clinical assessment. Squatting / Kneeling X Crawling X Balancing X

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X To reach supplies or perform clinical assessment. To

perform keyboarding. Work Above Shoulders X To reach supplies. Keyboarding X To document and access information. Wrist Flexion/Extension X While keyboarding. Handle/Grasp X Office supplies, assessment tools. Forceful Grasp X To perform various job duties. Fine Finger Manipulation X To perform various job duties. Hand Controls X Operate office equipment. Foot Controls X Raise/lower beds. Repetitive Motion X Body part: Upper

extremities Keyboarding





Talking X Must be able to effectively communicate. Hearing X Must be able to detect danger and effectively

communicate. Tasting/Smelling X Must be able to detect cleanliness. Visual - Near Acuity X Must be able to read documents. Visual - Far Acuity X Must be able to navigate facility. Visual - Depth Perception X Visual - Color Discrimination


Visual - Accommodation X Visual - Field Of Vision X To perform various job duties.


N S O F C Exposure to Weather X Work is performed predominantly indoors. Extreme Cold X Extreme Hot X Wet and / or Humidity X During inclement weather. Proximity to Moving Mechanical Parts

X


X May be exposed to household and hospital chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry. May use mask, goggles and gowns.

Exposure to Radiation X Other: Blood borne pathogens

X Minimal patient contact.


2






Analyst:

6/26/16




Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name








Job Title: Nurses Aid Certified (NAC) - Assisted Living

Brief Job Description/Duties: Assist residents who are lucid, ambulatory and non-combative with activities of daily living.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. lbs. 20 lbs. 10 lbs. 5 lbs. Carry lbs. lbs. 15 lbs. 5 lbs. lbs. Push / Pull lbs. 35 lbs. 25 lbs. 10 lbs. lbs.

Optional Comments:





Job Title: NAC - Assisted Living DOT Code: 355.674-014




Olympia, WA 98502 Claim No.: Job Title: Nurses Aid Certified (NAC)

- Assisted Living DOT #: 355.674-014



Job Title: Nurses Aid Certified (NAC) - Assisted Living





Brief Job Summary: Assist residents who are lucid, ambulatory and non-combative with activities of daily living.

Essential Job Functions: • Assist residents in bathing, dressing/undressing, and personal grooming.• Assist ambulatory residents in and out of bed by assisting them with lifting their feet only. Dispense pre-

dosed medications to residents.• Take vital signs such as blood pressure and temperature and record information.• Assist residents to dining areas for meals and assist in basic meal preparation and clean-up.• Assist with changing bed sheets, laundry, storage of clothes/linens, and light dusting/vacuuming.• Must be able to perform CPR.


Machine, Tools, Special Equipment, Personal Protective Equipment Used: Blood pressure cuff, thermometer, and grooming implements.

Based on F252-072-000 12- 2015 Page 2 of 7

Job Title: NAC - Assisted Living DOT Code: 355.674-014

Claimant: Claim No.: Job Title: NAC - Assisted Living Body Part Injured: DOT Code: 355.674-014




Sitting X OCCASIONAL sitting for periods up to 10-15 minutes at a time while feeding residents, visiting with residents and charting. Sitting typically does not occur more than one hour total each shift.

Standing X FREQUENT standing throughout the work day. Static standing occurs for periods up to 5 minutes at one time. Dynamic standing occurs for periods up to 15 minutes. Floor surfaces are generally carpet, linoleum, tile or concrete. Static and dynamic standing combined with walking occur CONSTANTLY throughout the work day. Standing positions are alternated on a frequent basis.

Walking X FREQUENT walking in assigned work area on carpeted, linoleum and tile floors. Walk combined with dynamic and static stand occur CONSTANTLY.


lbs.

Employee occasionally lifts items weighing up to 20 pounds, such as clothing, food, medical charts, supplies, grooming implements, linens, medications and equipment. Employee frequently lifts items weighing up to 10 pounds. All residents in this facility are ambulatory and patient transfers are not required. If a resident falls, employees contact 911 for assistance. Employee may assist patients in getting in/out of bed or in/out of bath chair, which will not require lifting more than 20 pounds

20 10 5

Carry (Dist.) ft.

N S O F C

lbs.

Employee may occasionally carry items weighing up to 15 pounds and frequently carry items weighing up to 5 pounds.

15 5


N S O F C

lbs. of force

FREQUENT push/pull cart with medical equipment and supplies requiring up to 10 pounds of force. SELDOM push/pull cart loaded with heavier supplies

35 25 10



Job Demand Frequency & Weight Activity Description requiring push/pull force up to 25 pounds. Typically cart rolls easily over concrete walkways, carpeting and tile. Push wheelchairs on a OCCASIONAL basis. In regards to pushing wheelchairs the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. Each employee performs CPR on a SELDOM basis. CPR is needed 1-2 times per week throughout the facility and multiple employees perform this function. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives – typically 1-4 minutes.

Job Demand Frequency Activity Description N S O F C Perform Work on Ladders X Climb Stairs X Twisting X Employee occasionally twists at the waist while

assisting residents with daily living tasks. Stooping / Bending X Employee occasionally bends at waist when assisting

residents with daily living tasks, performing light housekeeping duties or when preparing food. Employee must be able to perform CPR.

Squatting / Kneeling X Employee occasionally crouches when assisting residents with daily living tasks. On a rare basis, may need to kneel or crouch to retrieve items at floor level or to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee’s discretion.





Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Employee frequently reaches (non-weight bearing) with

¾ to full arm extension in all directions when assisting residents in daily living tasks.


Keyboarding X To access/document information. Wrist Flexion/Extension X While keyboarding. Handle/Grasp X Employee will constantly grasp and handle grooming

implements, blood pressure cuff, thermometer, clothing, medications and other related items. Handle/grasp activities are non-repetitive and intermittent.

Forceful Grasp X To perform various job duties. Fine Finger Manipulation X Employee occasionally and intermittently uses fine

finger manipulation when working with residents and recording/charting information.

Hand Controls X Employee may operate hand controls on office equipment or household/cleaning type equipment. May also operate hand controls on nursing equipment.

Foot Controls X The use of both hand and foot controls is required (i.e. wheelchair brakes, hydraulic beds, etc).



Talking X Good speaking and listening abilities are necessary, and the employee must be able to effectively communicate in the English Language with co-workers and residents.

Hearing X Good speaking and listening abilities are necessary, and the employee must be able to effectively communicate in the English Language with co-workers and residents.

Tasting/Smelling X Employee should be able to smell to discern if a resident is incontinent or to detect smoke, etc.

Visual - Near Acuity X Employee must have good vision to perform job tasks. Visual - Far Acuity X To navigate facility. Visual - Depth Perception X To perform various job duties. Visual - Color Discrimination







X


X Will be exposed to household and hospital chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry. May use mask, goggles and gowns.






Analyst:

6/26/16




Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name








Job Title: Physical Therapy Assistant

Brief Job Description/Duties: Prepares patients for physical therapy treatments and provides assistance to physical therapist.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. lbs. 25-50 lbs. 15 lbs. lbs. Carry lbs. lbs. 15 lbs. 5 lbs. lbs. Push / Pull lbs. lbs. 25 lbs. 15 lbs. lbs.

Optional Comments:





Job Title: Physical Therapy Assistant DOT Code: 355.354-010




Olympia, WA 98502 Claim No.: Job Title: Physical Therapy Assistant DOT #: 355.354-010



Job Title: Physical Therapy Assistant DOT Title: Physical Therapy Aide SVP: 4 DOT #: 355.354-010 Wage: Type of Industry: 573, Medical Services



Brief Job Summary: Prepares patients for physical therapy treatments and provides assistance to physical therapist.

Essential Job Functions: • Assists residents from room to physical therapy, either by wheelchair or walking with ambulatory residents.• Required to transfer residents prior to performing various exercises with the resident.• May utilize the assistance of another aid if necessary.• Assist residents with range of motion exercises, walking and light aerobic activities.• Document progress of individual residents.• Assist physical therapist in administering treatments, tests and evaluations of elderly residents.• Must be physically able to tolerate physical exertion.• Must be able to demonstrate and participate with the residents in light aerobic exercises or range of motion

exercises.

Training/Preparation Required: Over 3 months, up to 6 months. Must meet certification requirements.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Gym equipment, computer and telephone.



Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Physical Therapy Assistant DOT Code: 355.354-010

Claimant: Claim No.: Job Title: Physical Therapy Assistant Body Part Injured: DOT Code: 355.354-010


Sitting X Occasional sitting, from one to two hours per day usually while documenting information regarding residents.

Standing X Occasional standing, up to three hours per day on various surfaces (carpet, linoleum or tile); alternated with walking.

Walking X Occasional walking, up to three hours per day on various surfaces (carpet, linoleum or tile); alternated with standing.


lbs.

Lift up to 10 pounds when assisting resident in performing range of motion activities. Occasional lift of 25 pounds and up to 50 pounds when transferring residents (2 person lift).

25-50 15

Carry (Dist.) ft.

N S O F C lbs.

Various physical therapy items.

15 5


N S O F C

lbs. of force

Pushing/pulling occurs transporting residents in wheelchairs. Pushing/pulling for range of motion exercises or to use equipment.

25 15


Perform Work on Ladders X Climb Stairs X May demonstrate climbing short set of steps in therapy

room. Twisting X Occasional twisting may occur while demonstrating

exercises to residents. Stooping / Bending X Frequent bending/stooping is performed while assisting

residents with exercises. Squatting / Kneeling X Occasional crouching/squatting occurs while assisting

residents with exercises. Crawling X Balancing X Must be able to balance when transferring a resident or

assisting them with exercised.

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X When working with residents.


Based on F252-072-000 12- 2015 Page 3 of 6


Job Demand Frequency Activity Description Work Above Shoulders X Reaching at and above shoulder height while assisting

residents with range of motion exercises or light aerobic exercises. Reaching below shoulder height also occurs while assisting with range of motion exercises.

Keyboarding X To access and document information. Wrist Flexion/Extension X While keyboarding. Handle/Grasp X Frequent handling is used while assisting residents with

exercises. Frequent grasping is used when documenting progress of residents.

Forceful Grasp X To assist residents and to lift heavy items. Fine Finger Manipulation X Occasional fine finger manipulation is used while

documenting progress of resident. Some facilities may utilize a computer for charting.

Hand Controls X Occasional use of limited hand controls to flip a switch, push a button, etc.

Foot Controls X Repetitive Motion X Body part: Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X The ability to talk/hear is necessary for communicating with the residents and other aids and for taking instructions from physical therapist.

Hearing X The ability to talk/hear is necessary for communicating with the residents and other aids and for taking instructions from physical therapist.

Tasting/Smelling X Visual - Near Acuity X Must be able to read and document information. Visual - Far Acuity X Must be able to navigate facility. Visual - Depth Perception X Must be able to navigate facility and assist residents

safely. Visual - Color Discrimination


Visual - Accommodation X To perform various job duties. Visual - Field Of Vision X Must be able to navigate facility and assist residents

safely.


N S O F C Exposure to Weather X Extreme Cold X Extreme Hot X Wet and / or Humidity X


Based on F252-072-000 12- 2015 Page 4 of 6




X


X May be exposed to some infectious diseases and cleaning solutions.






Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 5 of 6


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Receptionist

Brief Job Description/Duties: Greets and directs visitors and residents within the facility. Answers and directs all calls coming into the facility's main switch board.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X X Lift lbs. lbs. 10 lbs. 2 lbs. lbs. Carry lbs. lbs. 10 lbs. lbs. lbs. Push / Pull lbs. lbs. 2 lbs. lbs. lbs.

Optional Comments:





Job Title: Receptionist DOT Code: 237.367-038




Olympia, WA 98502 Claim No.: Job Title: Receptionist DOT #: 237.367-038



Job Title: Receptionist DOT Title: Receptionist SVP: 4 DOT #: 237.367-038 Wage: Type of Industry: 249, Clerical and Kindred



Brief Job Summary: Greets and directs visitors and residents within the facility. Answers and directs all calls coming into the facility's main switch board.

Essential Job Functions: • Assist all visitors that come into the facility.• Know the proper procedures for fire drills and will notify security of any problems.• May deliver packages, flowers, etc. to residents as needed.• Distribute mail in mail room to residents' mail slots and staff mail boxes. Other clerical duties related to mail

distribution.

Training/Preparation Required: Over 3 months, up to 6 months of training/experience.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Computer, phone system, and public announcement system.



Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Receptionist DOT Code: 237.367-038

Claimant: Claim No.: Job Title: Receptionist Body Part Injured: DOT Code: 237.367-038


Sitting X Sit for six to seven hours out of an eight hour work day using a counter level surface and an office chair.

Standing X Occasional standing and walking, approximately one to two hours per shift.

Walking X Occasional standing and walking, approximately one to two hours per shift.


lbs.

Occasionally lift deliveries for residents weighing no more than five to 10 pounds.

10 2


N S O F C

lbs.

Occasionally lift deliveries for residents weighing no more than five to 10 pounds and potentially carry these items for up to 100 feet at a time.

10



Intermittent pushing and pulling to open/close doors and drawers may be necessary.

2


Perform Work on Ladders X Climb Stairs X Twisting X Stooping / Bending X Rare bending may be used when retrieving dropped

items from drawers. Squatting / Kneeling X Crawling X Balancing X

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X While keyboarding, answering the phone, sorting mail. Work Above Shoulders X Occasional reaching above shoulder height when

distributing mail. Occasionally reaching below shoulder height when retrieving supplies.

Keyboarding X To document and access information. Wrist Flexion/Extension X While keyboarding. Handle/Grasp X Frequent handling and grasping when writing

messages, sorting mail, etc. Forceful Grasp X To pick up items. Fine Finger Manipulation X Occasional to frequent fingering will be used when

keyboarding.


Based on F252-072-000 12- 2015 Page 3 of 6


Job Demand Frequency Activity Description Hand Controls X Intermittent use of the hand controls on the telephone,

headset, computer, public announcement system. Foot Controls X Repetitive Motion X Body part: Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X The ability to speak and hear is constantly required when communicating with others and when communicating with residents and visitors.

Hearing X The ability to speak and hear is constantly required when communicating with others and when communicating with residents and visitors.

Tasting/Smelling X Visual - Near Acuity X Necessary to read information. Visual - Far Acuity X When monitoring the outgoing and incoming visitors and

residents. Visual - Depth Perception X Visual - Color Discrimination

X

Visual - Accommodation X Visual - Field Of Vision X When monitoring the outgoing and incoming visitors and

residents.



X






Based on F252-072-000 12- 2015 Page 4 of 6





Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 5 of 6


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Recreation/Activities Therapy Assistant

Brief Job Description/Duties: Perform duties involving the planning and implementation of activities/programs, which meet the needs and interests for the physical, mental and psycho-social well-being of the residents; i.e., horticulture classes, group exercises, crafts and woodworking.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift 50-70 lbs. 11-50 lbs. 10 lbs. lbs. lbs. Carry lbs. lbs. 10 lbs. lbs. lbs. Push / Pull lbs. lbs. 25 lbs. lbs. lbs.

Optional Comments:





Job Title: Therapy Assistant DOT Code: 076.124-014




Olympia, WA 98502 Claim No.: Job Title: Recreation/Activities

Therapy Assistant DOT #: 076.124-014



Job Title: Recreation/Activities Therapy Assistant DOT Title: Recreational Therapist SVP: 6 DOT #: 076.124-014 Wage: Type of Industry: 573, Medical Services



Brief Job Summary: Perform duties involving the planning and implementation of activities/programs, which meet the needs and interests for the physical, mental and psycho-social well-being of the residents; i.e., horticulture classes, group exercises, crafts and woodworking.

Essential Job Functions: • Maintain documentation as required by the State and Federal regulations.• Assist with resident outings; may operate van.• Coordinate and instruct participation of volunteers with residents.• May be required to care for facility pets; i.e., dogs, cats, fish and birds.• Assist in maintenance of recreation equipment and supplies.• This is a somewhat physical position based on the required amount of walking and standing.• Transferring of patients does not occur often but employee is required to know the correct way to transfer

residents so as not to injure the resident or themselves.• Typically there is more than one Recreation Therapy Assistant available.

Training/Preparation Required: Over 1 year up to 2 years of training/experience.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Operate a van, use paints brushes, and other craft supplies.

Physical Requirements Frequency Scale Strength Work Pattern N = Never Sedentary Full-time S = Seldom (1-10 %, up to 48 min.) Light Part-time

Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Therapy Assistant DOT Code: 076.124-014

Claimant: Claim No.: Job Title: Therapy Assistant Body Part Injured: DOT Code: 076.124-014

O = Occasional (11-33%, 48 min. – 2 hrs. 25 min.) Medium Seasonal F = Frequent (34-66%, 2 hrs. 26 min. – 5 hrs. 35 min.) Heavy Hours Per Day



Sitting X Sitting occurs when driving the van and while documenting information regarding the residents. May sit for one to two hours per work day.

Standing X Standing and walking are alternated throughout the work day.

Walking X Walking and standing are alternated throughout the work day.


lbs.

Occasional lifting up to 10 pounds to lift various supplies used in recreational activities; i.e., paints, brushes, etc. Rare lifting of 11 to 50 pounds of supplies, tables, chair, etc. Rare lifting over 50 pounds to transfer resident from wheelchair with the assistance of others. Use of a transfer belt is required.

50-70 11-50 10


N S O F C

lbs.

Occasional carrying up to 10 pounds to lift and carry supplies used for recreation activities. Carrying over 10 pounds is not required.

10



Occasional pushing/pulling when assisting residents to recreation hall while resident is seated in wheelchair.

25


Perform Work on Ladders X May use short ladder or step stool to hang decorations, etc.

Climb Stairs X Rarely climb stairs or short stool to obtain items on higher shelves.

Twisting X Twisting at the waist to perform job duties. Twisting at neck level while driving.

Stooping / Bending X Frequent bending/stooping while working with seated residents at a table. The worker may bend over at the waist to monitor progress of resident.

Squatting / Kneeling X Frequent crouching/squatting is used while working with seated residents at a table. Crouching/squatting may be replaced by sitting or kneeling at the worker's discretion.

Crawling X Balancing X Must be able to balance if transferring a resident.


Based on F252-072-000 12- 2015 Page 3 of 6


Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Frequently reaching between shoulder and waist height

when directing or demonstrating activity. Frequent reaching below waist height during the course of day when assisting with residents.

Work Above Shoulders X Occasional reaching above shoulder height to reach items on shelves for various supplies.

Keyboarding X To access or document information. Wrist Flexion/Extension X When keyboarding or performing craft projects. Handle/Grasp X Handle/grasp during the course of the day while

documenting and working with hobbies or crafts Forceful Grasp X Forceful grasping is used when performing some tasks

and lifting heavy items. Fine Finger Manipulation X Occasional use of fine finger manipulation during the

course of day while assisting residents in the making of crafts.

Hand Controls X Occasionally use hand and foot controls when driving the van.

Foot Controls X Occasionally use hand and foot controls when driving the van.



Talking X The ability to speak and hear is constantly required during course of day to communicate with residents and other workers.

Hearing X The ability to speak and hear is constantly required during course of day to communicate with residents and other workers.

Tasting/Smelling X To detect cleanliness and safety hazards. Visual - Near Acuity X To perform crafts. Visual - Far Acuity X To drive vehicle and navigate facility. Visual - Depth Perception X To drive vehicle. Visual - Color Discrimination

X To perform crafts.

Visual - Accommodation X For various job duties. Visual - Field Of Vision X To drive vehicle.


Based on F252-072-000 12- 2015 Page 4 of 6



N S O F C Exposure to Weather X Exposure to both outside. Extreme Cold X Extreme Hot X Wet and / or Humidity X During inclement weather. Proximity to Moving Mechanical Parts

X


X May be exposed to paints, paint thinner, and other craft type chemicals. May be exposed to infectious disease.






Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 5 of 6


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Registered Nurse (RN) - Wellness Nurse – Assisted Living

Brief Job Description/Duties: Provides health education, counseling and appropriate nursing services that assist residents in living their lives.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted

Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X X Lift lbs. 25-50 lbs. 10-25 lbs. 10 lbs. lbs. Carry lbs. lbs. 10 lbs. 5 lbs. lbs. Push / Pull lbs. 25-35 lbs. 10 lbs. lbs. lbs.

Optional Comments:





Job Title: RN - Assisted Living DOT Code: 075.364-010




Olympia, WA 98502 Claim No.: Job Title: Registered Nurse (RN) -

Wellness Nurse – Assisted Living



Job Title: Registered Nurse (RN) - Wellness Nurse – Assisted Living

DOT Title: Nurse, General Duty




Brief Job Summary: Provides health education, counseling and appropriate nursing services that assist residents in living their lives.

Essential Job Functions: • In conjunction with the LPN Wellness Nurse, completes resident assessments prior to resident move in, 30

days after resident move in, semiannually and when there is a change in condition. • Functions as a health counselor and provides health education for residents. Communicates with

resident's family and Doctors on health-related issues. • Based on assessment, develops with the Director, the resident, the resident's family (when appropriate)

and staff a Service Package for each resident. • When appropriate, provides direct nursing services and assistance to residents.• Works closely with the Director to oversee staff development (Resident Service Associate initial and

ongoing training) and supervision.• In conjunction with the Director, oversees the Quality Assurance Program. Prepares incident reports

and communicates related information to families.• Monitors and oversees Medication Assistance Program.• Performs other duties as assigned by management to meet changing job related requirements.

Training/Preparation Required: Current Washington State RN License including current necessary training under Washington State WAC regulations. At least one year of experience.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Blood pressure cuff, thermometer, stethoscope, gloves, telephone, transfer belt, computer and medical equipment/supplies.

Based on F252-072-000 12- 2015 Page 2 of 7

Job Title: RN - Assisted Living DOT Code: 075.364-010

Claimant: Claim No.: Job Title: RN - Assisted Living Body Part Injured: DOT Code: 075.364-010




Sitting X While charting activities and medical information by computer and/or hand and communicating with families.

Standing X Intermittent with walking while making rounds and checking on residents. Floor surfaces are generally carpet, linoleum, tile or concrete.

Walking X Intermittent with standing while making rounds and checking on residents. Floor surfaces are generally carpet, linoleum, tile or concrete.


lbs.

FREQUENT lift of 0-10 pounds for resident files and individual medical supplies. Lifting up to 25 pounds required when stocking medical supplies. Lifting up to 50 pounds is rarely (1-2 time per month) required to assist or transfer residents. The correct use of a transfer belt is required to avoid injury to the resident or nurse. Lifting is performed from floor to shoulder level. Lifting over shoulder level is SELDOM.

25-50 10-25 10

Carry (Dist.) ft.

N S O F C

lbs.

FREQUENT up to 5 ponds. OCCASIONAL up to 10 pounds when carrying resident treatment bag or other items. Carts are used for moving items weighing more than 10 pounds, such as medical equipment and supplies.

10 5


N S O F C

lbs. of force

OCCASIONAL push/pull cart with medical equipment and supplies requiring up to 10 pounds of force. SELDOM push/pull cart loaded with heavier supplies requiring push/pull force up to 25 pounds. Typically cart rolls easily over concrete walkways, carpeting and tile. Push wheelchairs on a SELDOM basis. In regards to pushing wheelchairs

25-35 10


Based on F252-072-000 12- 2015 Page 3 of 7


Job Demand Frequency & Weight Activity Description the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. CPR is performed on a SELDOM basis - on average 2-4 times per year. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives – typically 1-4 minutes.


Perform Work on Ladders X Climb Stairs X Twisting X OCCASIONAL twisting at the waist may occur when

providing medical treatments, assisting in transfer or when applying/changing daily bandages and leg wraps.

Stooping / Bending X Bending required when providing treatment to residents, administering medications, taking vital signs and assisting seated residents. Must be able to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee’s discretion.


Crawling X Crawling is not a requirement of this position. Balancing X Must be able to balance when assisting residents with





Keyboarding X To access and document information. Wrist Flexion/Extension X While keyboarding.


Based on F252-072-000 12- 2015 Page 4 of 7


Job Demand Frequency Activity Description Handle/Grasp X FREQUENT grasping when handling pens/pencils for

documenting information into medical charts, when handling paperwork and while using various medical supplies/equipment (stethoscope, thermometer, medications, syringes, etc.).


Fine Finger Manipulation X OCCASIONAL fine finger manipulation while using the computer and telephone and when performing first aid and administering shots.

Hand Controls X OCCASIONAL intermittent use of various hand controls with knobs to turn, buttons to push and switches to flip as needed for blood pressure cuff and various other medical equipment.

Foot Controls X The use of foot controls is SELDOM. Repetitive Motion X Body part: Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X Necessary for communicating with others, safety awareness and for taking instructions from physicians and supervisor. Must be able to communicate in English.

Hearing X Necessary for communicating with others, safety awareness and for taking instructions from physicians and supervisor. Must be able to communicate in English.

Tasting/Smelling X Smell is required and necessary to detect dangerous odors when providing wound treatment and performing health assessment.

Visual - Near Acuity X CONSTANT for doing job effectively and correctly. Visual - Far Acuity X To navigate facility. Visual - Depth Perception X To perform various job duties. Visual - Color Discrimination




N S O F C Exposure to Weather X Extreme Cold X Extreme Hot X


Based on F252-072-000 12- 2015 Page 5 of 7



Wet and / or Humidity X Proximity to Moving Mechanical Parts

X


X Will be exposed to household chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry.






Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 6 of 7


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 7 of 7





Job Title: Registered Nurse, Primary Care - Nursing Home

Brief Job Description/Duties: The RN will direct, administer and record the care given to residents in an assigned section of the nursing facility.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X X Lift lbs. 25-50 lbs. 10-25 lbs. 10 lbs. lbs. Carry lbs. lbs. 10 lbs. 5 lbs. lbs. Push / Pull lbs. 35 lbs. 25 lbs. 10 lbs. lbs.

Optional Comments:





Job Title: RN - Nursing Home DOT Code: 075.364-010




Olympia, WA 98502 Claim No.: Job Title: Registered Nurse, Primary

Care - Nursing Home DOT #: 075.364-010



Job Title: Registered Nurse, Primary Care - Nursing Home

DOT Title: Nurse, General Duty




Brief Job Summary: The RN will direct, administer and record the care given to residents in an assigned section of the nursing facility.

Essential Job Functions: • Documentating and directing the other nursing staff in performing care for the residents.• Communicate with family members regarding the progress of the resident.• Assist visiting physicians in rounds.• Draw blood and obtain fluids to submit for lab work.• May be required to complete intravenous infusion/injection.• Record and issue appropriate medications.• May be required to work with Alzheimer's residents who are not cooperative.• Record and monitor all progress of residents and communicate with physicians.• May be required to assist in passing out trays to residents in dining area and assist in feeding.• Monitor work of other nursing staff in unit to ensure thoroughness.• Required to use telephones to communicate with physicians, arrange for transportation for doctor

appointments and contact families.• Make rounds to ensure cleanliness and proper care to residents.• Coordinate care of residents.• Manage all NAC staff in section.• Assist staff members according to needs.• Follow set protocol in emergency situation.

Training/Preparation Required: Current Washington State RN License including current necessary training under Washington State WAC regulations. At least one year of experience.

Based on F252-072-000 12- 2015 Page 2 of 7

Job Title: RN - Nursing Home DOT Code: 075.364-010

Claimant: Claim No.: Job Title: RN - Nursing Home Body Part Injured: DOT Code: 075.364-010

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Computer, telephone, gowns, goggles, gloves, masks, Accucheck (Blood Sugar), scale, blood pressure cuff, bladder scanner, pulse oximeter, thermometer, IV pumps, portable oxygen and various first aid supplies and equipment.




Sitting X OCCASIONAL while charting activities and medical information by computer and/or hand, phoning doctors, taking orders and communicating with families.

Standing X OCCASIONAL standing intermittent with walking while making rounds and checking on residents. Employer states static stand up to 2 minutes at one time when administering treatments. Twice per week static standing is required up to 45 minutes for longer treatments. Floor surfaces are generally carpet, linoleum, tile or concrete.

Walking X FREQUENT walking intermittent with standing. Floor surfaces are generally carpet, linoleum, tile or concrete.


lbs.

FREQUENT lift up to 10 pounds for resident files and supplies. Lifting 10-25 pounds OCCASIONALLY required for medical supplies/equipment. SELDOM lifting up to 50 pounds to assist and transfer residents with transfer belt. The correct use of a transfer belt is required to avoid injury to the resident or nurse. Vera Lift and Vander Lifts are used to minimize weight. Lifting primarily performed from floor to shoulder level. Lifting over shoulder level is SELDOM.

25-50 10-25 10

Carry (Dist.) ft.

N S O F C

lbs.

FREQUENT up to 5 pounds. OCCASIONAL 5-10 pounds to move items from one location in the facility to another. Carts are available for heavier supplies and/or equipment.

10 5



Job Demand Frequency & Weight Activity Description Pushing/ Pulling (Dist.) ft.

N S O F C

lbs. of force

FREQUENT push/pull cart with medical equipment and supplies requiring up to 10 pounds of force. SELDOM push/pull cart loaded with heavier supplies requiring push/pull force up to 25 pounds. Typically cart rolls easily over concrete walkways, carpeting and tile. Push wheelchairs on an OCCASIONAL basis. In regards to pushing wheelchairs the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. Each employee performs CPR on a SELDOM basis. CPR is needed 1-2 times per week throughout the facility and multiple employees perform this function. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives – typically 1-4 minutes.

35 25 10


Perform Work on Ladders X Climb Stairs X Twisting X OCCASIONAL twisting may occur while providing

patient care. Stooping / Bending X OCCASIONAL bending may occur when providing

treatment to residents, administering medications, taking vital signs and assisting seated residents, etc. Must be able to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee’s discretion.








Work Above Shoulders X Above shoulder level – OCCASIONAL when attending patients with tubes and IVs and to obtain supplies on shelves.

Keyboarding X To access and document information. Wrist Flexion/Extension X While keyboarding. Handle/Grasp X FREQUENT handling paperwork, pens/pencils,

telephone and various medical supplies/equipment (i.e. stethoscope, thermometer, medications, syringes, etc).


Fine Finger Manipulation X OCCASIONAL fine finger manipulation while using the computer keyboard, writing, and when performing first aid, administering shots and medications.

Hand Controls X FREQUENT use of various hand controls with knobs to turn, buttons to push and switches to flip as needed for blood pressure cuff and various other medical equipment.

Foot Controls X The use of foot controls may be required for hydraulic beds, wheelchair brakes, etc.



Talking X Necessary for safety awareness and for communicating and taking instructions from physicians, labs, pharmacists, families and supervisor. Ability to read, write, and speak English.

Hearing X Necessary for safety awareness and for communicating and taking instructions from physicians, labs, pharmacists, families and supervisor. Ability to read, write, and speak English.

Tasting/Smelling X Smell is required and necessary to detect dangerous odors, provide wound treatment and to perform health assessment/diagnosis.

Visual - Near Acuity X Must be able to read labels, doctor’s instructions, medication orders, charts and medical history.

Visual - Far Acuity X To navigate facility. Visual - Depth Perception X To perform various job duties. Visual - Color Discrimination




Job Demand Frequency Activity Description Visual - Accommodation X To perform various job duties. Visual - Field Of Vision X CONSTANT for doing job effectively and correctly.



X


X Will be exposed to household and hospital chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry. May use mask, goggles and gowns. Possible exposure to needle pricks.






Analyst:

6/26/16




Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 7 of 7





Job Title: Residential Service Associate (RSA) - Assisted Living

Brief Job Description/Duties: Responsible for providing services that will support and assist residents in activities of daily living.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. 50 lbs. 20 lbs. 10 lbs. 5 lbs. Carry lbs. lbs. 15 lbs. 5 lbs. lbs. Push / Pull lbs. 35 lbs. 25 lbs. 10 lbs. lbs.

Optional Comments:





Job Title: RSA - Assisted Living DOT Code: 355.674-014




Olympia, WA 98502 Claim No.: Job Title: Residential Service

Associate (RSA) - Assisted Living



Job Title: Residential Service Associate (RSA) - Assisted Living





Brief Job Summary: Responsible for providing services that will support and assist residents in activities of daily living.

Essential Job Functions: • Based on resident-negotiated service agreements, provides assistance with medication, dressing,

grooming, showering, dining, toileting, incontinence management, transfers and mobility/ambulation. • Prepares, serves and cleans up breakfast. Completes final meal preparation, meal set up, meal serving

and meal clean up for lunch and dinner. • Occasionally provides extra housekeeping and laundry services for residents based on their negotiated

service agreement. Strips beds, washes sheets, towels once per week; cleans kitchen and mattress pads as needed.

• Provides housekeeping services for common areas (vacuuming, wipe down/sanitation, dishwashing, etc).• Helps Activity Director and/or assists residents to group and individual activities designed to meet their

needs, interests and capabilities.• In cardiac/emergency situations first calls 911, then Wellness Nurse on staff.• Reports to Wellness Nurse and works under little supervision. Performs other duties as assigned to

meet changing job related requirements.• Must be able to perform CPR.


Machine, Tools, Special Equipment, Personal Protective Equipment Used: Cart, blood pressure cuff, basic medical supplies, gloves, scale, thermometer; transfer belt.

Based on F252-072-000 12- 2015 Page 2 of 8

Job Title: RSA - Assisted Living DOT Code: 355.674-014

Claimant: Claim No.: Job Title: RSA - Assisted Living Body Part Injured: DOT Code: 355.674-014




Sitting X Occasional sitting while charting activities and when talking with residents.

Standing X FREQUENT standing intermittent with walking is performed for up to two hours at a time while making rounds and checking on residents. Floor surfaces are generally carpet, linoleum, tile or concrete.

Walking X FREQUENT walking intermittent with standing is performed for up to two hours at a time while making rounds and checking on residents. Floor surfaces are generally carpet, linoleum, tile or concrete.


lbs.

Waist to Shoulder Level: CONSTANT - up to 5 pounds of residents’ personal items (i.e. clothing, food items, medical charts and supplies). FREQUENT - up to 10 pounds. OCCASIONAL - 11-20 pounds of soiled bed linens, resident belongings, large size containers from food and supply delivery carts and when assisting a resident in bathing or dressing. SELDOM – 21 pounds to 50 pounds. Employer states lifting up to 50 pounds when assisting or transferring a resident - occurs on average once per week. Below waist and above shoulder level: SELDOM – up to 5 pounds for supplies and dishes located at lower and higher levels.

50 20 10 5

Carry (Dist.) ft.

N S O F C

lbs.

Carry up to 5 pounds of resident’s personal items (i.e. laundered clothing, food items, medical charts and supplies). OCCASIONALLY carry 15 pounds when transporting laundry baskets and soiled bed linens to a utility area and when

15 5


Based on F252-072-000 12- 2015 Page 3 of 8


Job Demand Frequency & Weight Activity Description moving supplies. Carts are used for moving items weighing more than 15 pounds.


N S O F C

lbs. of force

FREQUENT push/pull cart with supplies requiring up to 10 pounds of force. SELDOM push/pull cart loaded with heavier supplies requiring push/pull force up to 25 pounds. Typically cart rolls easily over concrete walkways, carpeting and tile. Push wheelchairs on an OCCASIONAL basis. In regards to pushing wheelchairs the ratio is 8:1, so a 150 pound person in a wheelchair that weighs approximately 50 pounds would require 25 pounds of initial push force and then 20 pounds of kinetic force to maintain the pushing. CPR is performed on a SELDOM basis - on average 2-4 times per year. The amount of push force required for CPR chest compression is estimated at 110 pounds maximum. This is a shared force for each upper extremity and the trunk flexion force application would be a shared event, thus each body segment would apply a maximum of approximately 33 pounds of force. CPR is administered until EMS arrives – typically 1-4 minutes.

35 25 10


Perform Work on Ladders X Climb Stairs X Twisting X OCCASIONAL twisting at the waist while preparing

food, vacuuming, doing laundry, transferring resident or assisting in daily living.

Stooping / Bending X OCCASIONAL bending at waist and neck while assisting resident in bathing, loading/unloading dish washer, loading/unloading laundry washer/drying and when performing light housework. Must able to perform CPR.

Squatting / Kneeling X OCCASIONAL crouching/squatting may occur while bathing and dressing a resident or using the washer and dryer. On a rare basis, may need to kneel or crouch to retrieve items at floor level or to perform CPR. Crouch, bend, stoop and kneel may often be used interchangeably at employee’s discretion.

Crawling X


Based on F252-072-000 12- 2015 Page 4 of 8


Job Demand Frequency Activity Description Balancing X Must be able to balance when assisting residents with


Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Waist to shoulder level – FREQUENT when assisting

residents in changing bed linens, serving food, working in the kitchen, doing laundry and cleaning. Below waist level – FREQUENT when assisting residents with dressing and bathing, performing kitchen duties, doing laundry and reaching items located in dishwasher and oven. Bilateral reach is required with 3/4 to full arm extension.


Keyboarding X To access/document information. Wrist Flexion/Extension X While keyboarding. Handle/Grasp X CONSTANT grasping when handling residents’

personal items, eating utensils, kitchen equipment, household appliances and when preparing meals and doing laundry.

Forceful Grasp X OCCASIONAL forceful grasp used when pushing resident in wheelchair. Grasping for transferring patients occurs on an infrequent weekly basis.

Fine Finger Manipulation X OCCASIONAL fine finger manipulation occurs while documenting residents’ medical charts, administering daily medications and as needed for buttons and laces when dressing.

Hand Controls X OCCASIONAL intermittent use of various hand controls with knobs to turn, buttons to push and switches to flip as needed for laundry, kitchen and vitals.

Foot Controls X The use of foot controls is OCCASIONAL (i.e. brakes on wheelchairs, etc).



Talking X The ability to speak and hear is necessary for communicating with residents and other aids and for taking instructions from Wellness Nurse and requests from residents.

Hearing X The ability to speak and hear is necessary for communicating with residents and other aids and for taking instructions from Wellness Nurse and requests from residents.


Based on F252-072-000 12- 2015 Page 5 of 8


Job Demand Frequency Activity Description Tasting/Smelling X Smell is required and necessary to detect safety and

sanitary odors. Visual - Near Acuity X Employee must have good vision to perform job tasks. Visual - Far Acuity X To navigate facility. Visual - Depth Perception X To perform various job duties. Visual - Color Discrimination




N S O F C Exposure to Weather X Walking between different residential units and the

office building will expose worker to weather conditions. Extreme Cold X Extreme Hot X Wet and / or Humidity X During inclement weather. Proximity to Moving Mechanical Parts

X


X Will be exposed to household chemicals, human waste and bodily fluids, infection and viruses and/or sanitation chemicals. May use safety gloves for patient care, sanitation and laundry. May use mask, goggles and gowns.







Based on F252-072-000 12- 2015 Page 6 of 8


Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 7 of 8


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 8 of 8





Job Title: Security Guard

Brief Job Description/Duties: Protects facility property from damage or loss from fire, robbery, and other hazards.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. 20 lbs. 10 lbs. 3 lbs. lbs. Carry lbs. 20 lbs. 10 lbs. lbs. 3 lbs. Push / Pull lbs. 50 lbs. 5 lbs. lbs. lbs.

Optional Comments:





Job Title: Security Guard DOT Code: 372.667-034




Olympia, WA 98502 Claim No.: Job Title: Security Guard DOT #: 372.667-034



Job Title: Security Guard DOT Title: Security Guard SVP: 3 DOT #: 372.667-034 Wage: Type of Industry: 138, Any Industry



Brief Job Summary: Protects facility property from damage or loss from fire, robbery, and other hazards.

Essential Job Functions: • Checks various doors to ensure locked through building complex.• May be required to turn on outside and inside lights.• Required to keep a log of all incidents during the course of shift.• On a rare occasion this employee may be required to chase after trespassers but can call upon the

assistance of the police if this should occur.• Although this is a somewhat sedentary position with very light lifting, the employee may be required to

restrain a trespasser on occasion.• A hand-held radio is usually available to contact help if necessary.• May operate vehicle to patrol property.

Training/Preparation Required: Over 30 days up to 3 months. Ability to chase and restrain an individual.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Hand-held radio and telephone.



Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Security Guard DOT Code: 372.667-034

Claimant: Claim No.: Job Title: Security Guard Body Part Injured: DOT Code: 372.667-034


Sitting X Rare sitting, usually only while on breaks or when driving a vehicle.

Standing X Standing alternated with walking on surfaces of carpeting, linoleum, tile or concrete.

Walking X Walking alternated with standing on surfaces of carpeting, linoleum, tile or concrete.


lbs.

Lift a hand-held radio weighing approximately 3-pounds. Pick up litter on the grounds, weighing less than one pound. Rarely lift and deliver parcels to residents, which do not exceed 20-pounds. May rarely need to restrain a trespasser. Usually, the worker will call for assistance from police.

20 10 3


N S O F C

lbs.

Carry a 3-pound hand-held radio. Not required to carry anything weighing over 20 pounds.

20 10 3


N S O F C

lbs. of force

Occasionally push/pull doors or desk drawer. Rare push/pull in the process of apprehending a trespasser if the individual is caught and restrained.

50 5


Perform Work on Ladders X Climb Stairs X Occasionally may be required to climb stairs up several

flights. Twisting X Rare twisting will be performed. Stooping / Bending X Bending/stooping while patrolling/making checks of the

facility. Squatting / Kneeling X Rare squatting/crouching will be performed. Crawling X Balancing X

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Occasional reaching between waist and shoulder height

when checking doors to ensure they are locked. Work Above Shoulders X Rare reaching below waist or overhead. Keyboarding X May access and document information using a

keyboard. Wrist Flexion/Extension X While keyboarding.


Based on F252-072-000 12- 2015 Page 3 of 6


Job Demand Frequency Activity Description Handle/Grasp X Frequently required to handle a radio, grasp doors/door

knobs, etc.. Forceful Grasp X Frequently required to handle a radio, grasp doors/door

knobs, etc.. My use force to restrain an individual. Fine Finger Manipulation X May be required to use the keyboard, telephone, radio,

etc. Hand Controls X Intermittently use hand controls such as push button,

dial turn, flipped switch, etc. Intermittent use of hand and foot controls to operate a vehicle as directed by the employer.

Foot Controls X Intermittently use hand controls such as push button, dial turn, flipped switch, etc. Intermittent use of hand and foot controls to operate a vehicle as directed by the employer.



Talking X Necessary for communicating and taking instruction from others.

Hearing X Necessary for communicating and taking instruction from others.

Tasting/Smelling X The sense of smell is needed to assess the odor of smoke/fire.

Visual - Near Acuity X Necessary for doing the job effectively and correctly. Visual - Far Acuity X Necessary for doing the job effectively and correctly. Visual - Depth Perception X Necessary for doing the job effectively and correctly. Visual - Color Discrimination

X Necessary for doing the job effectively and correctly.

Visual - Accommodation X Necessary for doing the job effectively and correctly. Visual - Field Of Vision X Necessary for doing the job effectively and correctly.


N S O F C Exposure to Weather X May patrol around the exterior of the property. Extreme Cold X Extreme Hot X Wet and / or Humidity X During inclement weather. Proximity to Moving Mechanical Parts

X

Exposure to Explosives X Atmospheric Conditions X Exposed Heights X


Based on F252-072-000 12- 2015 Page 4 of 6



Exposure to Electricity X Exposure to Toxic / Caustic Chemicals







Analyst:

6/26/16



Based on F252-072-000 12- 2015 Page 5 of 6


Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name




Based on F252-072-000 12- 2015 Page 6 of 6





Job Title: Stock Clerk

Brief Job Description/Duties: Receive and verify food coming into the facility.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. 50 lbs. 30 lbs. 10 lbs. lbs. Carry lbs. lbs. 30 lbs. 10 lbs. lbs. Push / Pull lbs. lbs. 15 lbs. lbs. lbs.

Optional Comments:





Job Title: Stock Clerk DOT Code: 222.387-058




Olympia, WA 98502 Claim No.: Job Title: Stock Clerk DOT #: 222.387-058



Job Title: Stock Clerk DOT Title: Stock Clerk SVP: 4 DOT #: 222.387-058 Wage: Type of Industry: 249, Clerical & Kindred



Brief Job Summary: Receive and verify food coming into the facility.

Essential Job Functions: • Record information for reordering.• May be required to rotate stock to ensure timely food use.• Store various food in refrigerator or dry storage room.• Count and verify incoming food to ensure that the order is correct.• Take inventory of available stock and reorder according to facility needs or menu created by dietitian.• May be required to sweep and mop storage areas.• The worker may be required to assist elsewhere within the facility when not performing stock clerk duties;

such as assist in the kitchen, dishwashing or preparing meals.• May also contribute to planning the meals with the director of Dietary Services.• Most employees are also required to perform other tasks other than stock room work.

Training/Preparation Required: Over 3 months up to 6 months.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Hand truck

Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Stock Clerk DOT Code: 222.387-058

Claimant: Claim No.: Job Title: Stock Clerk Body Part Injured: DOT Code: 222.387-058




Sitting X Occasional sitting is performed for one to two hours during a work day; intermittent with standing/walking.

Standing X Occasional to Frequent standing, for three to four hours out of an eight hour work day on primarily linoleum or tile floor surfaces.

Walking X Occasional to Frequent walking, for three to four hours out of an eight hour work day on primarily linoleum or tile floor surfaces.


lbs.

Frequent lifting of various canned products. Occasional lifting of boxes filled with various food stuffs weighing up to 30 pounds. Seldom lifting of bags of potatoes or other heavy items. No lifting over 50 pounds.

50 30 10


N S O F C lbs.

A hand truck is available to move heavy items. 30 10



To move hand truck and to clean work area. 15


Perform Work on Ladders X Climb Stairs X Climb a step ladder to reach higher shelves in stock

room. Twisting X Twisting while sweeping and mopping the storage areas

or when rotating stock. Stooping / Bending X Bending/stooping occurs while taking inventory or

stocking food on lower shelves. Squatting / Kneeling X Crouching/squatting occurs while taking inventory of

food on lower shelves. Intermittent with bending. Crawling X



Job Demand Frequency Activity Description Balancing X Maintain balance on the step-ladder.

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Reach at and below shoulder height when counting

stock. Work Above Shoulders X Reach above shoulder height when checking inventory

on higher shelves or placing received stock onto upper shelves.

Keyboarding X May record inventory data using a keyboard. Wrist Flexion/Extension X To perform job duties. Handle/Grasp X Handle various food items; i.e., boxes and cans of

various prepared food substances. Forceful Grasp X Grasp canned food items, boxes, pen/pencil, and paper

for inventory. Fine Finger Manipulation X To record inventory. Hand Controls X May operate some basic controls. Foot Controls X Repetitive Motion X Body part: Arms Reaching and handling. Vibratory Tasks - Low X Vibratory Tasks - High X


Talking X Necessary for communicating with others and taking instructions from others.

Hearing X Necessary for communicating with others and taking instructions from others.

Tasting/Smelling X Visual - Near Acuity X Necessary for counting and ensuring correctiveness of

paperwork. Visual - Far Acuity X Visual - Depth Perception X To perform various job duties. Visual - Color Discrimination

X To differentiate between different items.

Visual - Accommodation X Visual - Field Of Vision X To navigate facility.


N S O F C Exposure to Weather X Extreme Cold X To store items in walk-in refrigerator. Extreme Hot X In oven and dish washing areas of the kitchen. Wet and / or Humidity X Kitchen area may be wet.





X


X May be exposed to some cleaning solutions.






Analyst:

6/26/16




Medical Provider




Comments:




Treatment plan:




________________________________________________________ _________________________ Signature Date

________________________________________________________ Print Name





1038M – Limit one per day 1028M – Additional review, up to 5 per

worker per day

Transitional Work Options Worker: Claim No:

SUMMARY OF CRITICAL PHYSICAL DEMANDS AND JOB DUTIES:

FEEDING PATIENTS: In this transitional option, the employee will assist with placing bibs on patients before meals, serving trays in the dining room and pouring liquids, cutting meat and other foods, pouring coffee, tea and other drinks, feeding patients after they are positioned, recording the input and output charts, returning trays to cart, assist with brushing teeth, and pick up water pitchers and redistribute with ice and water after the kitchen has cleaned the pitchers. Physically this job requires intermittent standing and walking predominately, for two hours at a time up to eight hours out of an eight-hour day. There is intermittent sitting that can be performed while doing charting and while assisting with some feeding activities. Lifting would be up to a maximum of 10 pounds. There would be frequent reaching, grasping, and handling in this position. There would be occasional bending and very rare kneeling or crouching. The majority of reaching would be at waist to chest height, although reaching would be performed at all ranges of motion. There would be some intermittent pushing or pulling of food trays requiring minimal force.

PHYSICIAN REVIEW: APPROVE______ DISSAPPROVE ______

DIRECT PATIENT CARE-PERSONAL HYGIENE ASSISTANCE: This transitional option consists of assisting with washing faces and hands for meals, sorting socks, performing minor mending, shampooing hair, assisting with brushing teeth, trimming finger and toe nails, combing hair, shaving male patients, assisting with putting away clothing, cleaning closets, helping with activities, and delivering water pitchers. The majority of the activities are performed while in a standing and walking position, although there may be intermittent sitting performed while doing mending, sorting socks, or other miscellaneous activities. Lifting would be up to a maximum of 10 pounds, with carrying only necessary for short distances. There would be occasional bending and twisting performed, and rare kneeling or squatting. There would be occasional pushing and pulling consisting of a water cart, with frequent handling, grasping, fingering and reaching at all ranges of motion.

PHYSICIAN REVIEW: APPROVE______ DISAPPROVE______

NON DIRECT PATIENT CARE ACTIVITIES LEVEL I: This position consists of performing activities such as labeling beds and drawers, folding laundry, dusting, clearing dishes, adjusting bed heights, marking clothing and belongings, organizing drawers, delivering mail, taking vital signs, taking pictures of new admissions, assisting patients with hand work activities, completing flow charts, wiping off the microwave and checking the showers for wash clothes and soap. The majority of these activities are performed while standing and walking, although there may be very intermittent sitting performed. Lifting ranges up to 10 pounds, with carrying performed up to 10 pounds for 50 to 100 feet. There is occasional pushing and pulling, and frequent


Claim No: _________________ Worker: _________________

Job Analysis – Transitional Work Options Page 2

handling, and grasping required. There is occasional bending, kneeling or crouching. Reaching is performed at all ranges of motion.


NON DIRECT PATIENT CARE ACTIVITIES LEVEL II: These types of activities consist of transporting soiled linen to the holding area, washing walls, washing windows and pictures, cleaning up after meals, cleaning toilet seats, cleaning urine and other accidents from the floor, defrosting and cleaning the refrigerator, assisting with washing the body after death and washing the wheelchairs or shower chairs. These activities require standing and frequent bending, and occasional kneeling, or crouching. There may be frequent pushing and pulling in this position. There is constant reaching at all ranges of motion, and frequent grasping and handling. Lifting ranges up to 25 pounds.


OFFICE CLERK: In this transitional position the worker would assist with greeting visitors, answering the telephone, taking messages, performing filing, entering information into the computer, and performing copying as needed. This position is predominately performed in a seated position, although there would also be intermittent standing and walking around the office area. Lifting would be a maximum of 10 pounds. There would be occasional pushing and pulling of desk drawers and file drawers requiring minimal force. There would be rare kneeling, crouching, or bending required in this position. Reaching would be predominately at wait to chest height, with frequent grasping, handling, fingering and feeling.


TRANSPORTING PATIENTS AND EQUIPMENT: Push residents in wheelchairs around facility on linoleum floors, push carts with meal trays, push laundry carts around facility. These activities require pushing or pulling with 20-40 lbs. force, standing & walking, and occasional bending & kneeling or crouching.


Work Schedule: Will be variable depending on specific physician recommendations.

Physician comments (please document how many hours per day the worker can work and any physical restrictions):

Physician Date





Job Title: Wait Person

Brief Job Description/Duties: Serves food to customers in an informal dining area.


Worker will: Never


Occasional 11-33%

1-3 hours

Frequent 34-66%

3-6 hours

Constant 67-100%

Unrestricted Sit X Stand X Walk X Work on ladders X Climb Stairs X Twist X Bend / Stoop X Squat / Kneel X Crawl X Reach X Work above shoulders X Keyboard X Wrist (flexion/extension) X Grasp (forceful) X Fine manipulation X Operate foot controls X Vibratory tasks; high impact X Vibratory tasks; low impact X Lift lbs. lbs. 25-30 lbs. 1-10 lbs. lbs. Carry lbs. lbs. 25-30 lbs. 1-10 lbs. lbs. Push / Pull lbs. lbs. 10 lbs. lbs. lbs.

Optional Comments:





Job Title: Wait Person DOT Code: 311.477-030




Olympia, WA 98502 Claim No.: Job Title: Wait Person DOT #: 311.477-030



Job Title: Wait Person DOT Title: Waiter/Waitress, Informal SVP: 3 DOT #: 311.477-030 Wage: Type of Industry: 453, Hotel & Restaurant



Brief Job Summary: Serves food to customers in an informal dining area.

Essential Job Functions: • Greet customers, take orders, serve food and drinks.• Process cash, checks, and credit cards for payment.• Ensure cleanliness of assigned section, utensils, glasses, and general area. Pick up any & all debris on

floor, and promptly remove empty• glassware & dishes from tables.• Uses suggestive selling techniques to advise customers on menu selections, fresh offerings, and desserts,

etc.

Training/Preparation Required: Must have an excellent customer service orientation, and pleasant and cheerful disposition. Must be reliable, and have good accuracy & attention to detail regarding menu items and ordering. Must hold any required certifications.

Machine, Tools, Special Equipment, Personal Protective Equipment Used: Tray, cash register, credit card processing equipment, tray stands, dining utensils, etc.



Based on F252-072-000 12- 2015 Page 2 of 6

Job Title: Wait Person DOT Code: 311.477-030

Claimant: Claim No.: Job Title: Wait Person Body Part Injured: DOT Code: 311.477-030


Sitting X Standing X Standing and walking are performed for two to three

hours at a time on carpeted and tile surfaces. Maximum walking distance at one time (from food service area to dining area) is 100 - 150 feet.

Walking X Standing and walking are performed for two to three hours at a time on carpeted and tile surfaces. Maximum walking distance at one time (from food service area to dining area) is 100 - 150 feet.


lbs.

Frequent lifting and carrying of 1 - 10 lbs (plates, glasses, water, drinks), with occasional lifting and carrying of trays of food/drinks weighing up to 25 - 30 lbs. Trays are lifted from counter height (40"), and placed at table height (29"). Actual specifics of the lifting and carrying requirements will depend upon the dishes and arrangement of the individual restaurant.

25-30 1-10

Carry (Dist.) ft.

N S O F C

lbs.

Frequent lifting and carrying of 1 - 10 lbs (plates, glasses, water, drinks), with occasional lifting and carrying of trays of food/drinks weighing up to 25 - 30 lbs. Trays are lifted from counter height (40"), and placed at table height (29"). Actual specifics of the lifting and carrying requirements will depend upon the dishes and arrangement of the individual restaurant.

25-30 1-10



Occasional pushing or pulling of tables, chairs, etc. may be performed while providing customer service.

10


Perform Work on Ladders X Climb Stairs X Climbing stairs will vary, depending upon the actual

restaurant chosen. Twisting X Frequent twisting is performed while serving food and

drinks and setting up trays, etc. Stooping / Bending X Frequent bending is performed while serving food and

drinks, and clearing tables. Squatting / Kneeling X Rare crouching/squatting would be performed, ordinarily

when picking up debris from the floor.



Job Demand Frequency Activity Description Crawling X Balancing X Must be able to balance food/beverages on tray.

Job Demand Frequency Activity Description (Left/Right/Both) N S O F C Reach Waist to Shoulder X Reaching at waist to chest level to serve food, clean

tables and collect payment. Work Above Shoulders X Reaching overhead and to ground level to obtain

supplies, and to pick up debris on the floor. Keyboarding X Wrist Flexion/Extension X Handle/Grasp X Repetitive grasping and handling is required to serve

customers food and drinks. Forceful Grasp X Repetitive grasping and handling is required to serve

customers food and drinks. Fine Finger Manipulation X Finger pinch and fine finger manipulation is utilized on

an occasional basis. Waitpersons perform cash & credit card transactions, requiring intermittent keying.

Hand Controls X Intermittent use of hand controls of the cash register and credit card machine, using push buttons.

Foot Controls X Repetitive Motion X Body part: Arms/Hands To serve food. Vibratory Tasks - Low X Vibratory Tasks - High X

Job Demand Frequency Activity Description N S O F C Talking X Must be able to communicate clearly with customers

and supervisors in a persuasive manner. Hearing X Must be able to communicate clearly with customers

and supervisors in a persuasive manner. Tasting/Smelling X Not required, although helpful to advise customers of

the various tastes of prepared dishes. Visual - Near Acuity X Must be able to read menu. Visual - Far Acuity X Must be able to see to navigate around the dining room

to serve food. Visual - Depth Perception X To navigate facility while balancing trays of

food/beverages. Visual - Color Discrimination

X

Visual - Accommodation X Visual - Field Of Vision X To navigate facility while balancing trays of

food/beverages.




N S O F C Exposure to Weather X Extreme Cold X Extreme Hot X Wet and / or Humidity X May be exposed to wet areas in the kitchen. Proximity to Moving Mechanical Parts

X


X May use cleaning agents. May be exposed to illness from residents at the facility.


3

Analyst’s Comments: Possible Employer Modifications:

Note: The information for this job analysis was gathered by either on-site observation, interview and / or is representative of the labor market as indicated on page one. Additional data may have been obtained from standardized industry resources such as the DOT, GOE, COJ, OOH, WOIS and O-NET. On occasion, practicality and feasibility prevent the direct observation and/or gathering of objective, quantifiable data. For this reason, a “best estimate” may have been used. Analyst:

6/26/16




Medical Provider




Comments:




Treatment plan:

The above named injured worker is permanently restricted from performing the physical activities

described in this job analysis based on the following physical limitations:



________________________________________________________ _________________________ Signature Date ________________________________________________________ Print Name




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