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Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)Scale of FeesAnnual Increase in Medical Tariffs for Medical Service Providers - 2018Physiotherapy Services, Occupational Therapy Services and Chiropractor ServicesOccupational Therapy ServicesAnnexure C : Work site assessment report |
ANNEXURE C
WORK SITE ASSESSMENT REPORT
COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT, 1993 (ACT NO. 130 OF 1993)
Employee Information |
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Employee Name: |
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Identity Number: |
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Diagnosis: |
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Date of injury: |
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Date of report: |
Company Information |
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Name of company: |
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Contact person: |
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Address: |
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Telephone number: |
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Email address: |
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Occupational Health Doctor and/or Nurse and contact number: |
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Employer Representative: |
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Designation: |
Work status |
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Current Work Status: |
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Signed off on IOD leave |
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Working in accommodated duties |
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Able to complete their own job however a number difficulties noted |
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Completing own occupation |
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Working accommodated hours |
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Signed off on other leave |
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Fit for work, but not yet returned |
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Working in a temporary alternate occupation |
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Working in permanent alternate occupation |
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Date returned to work - if currently working |
Current job information |
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Job title: |
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The position is defined as: |
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Sedentary |
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Light |
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Medium |
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Heavy |
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Very heavy |
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Position is |
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Permanent |
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Contract |
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Normal work hours: |
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Overtime hours: |
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Normal safety equipment utilized: |
Job Analysis |
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Job description: (A brief overview of the requirements of the job)
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Job tasks |
As described by the employee |
Reported difficulties - if currently working: |
1 |
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2 |
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3 |
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4 |
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5 |
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6 |
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Employer Comments: |
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Inherent physical demands of the job |
Return to work plan |
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Given the employee's current physical abilities, it is considered that they are currently: |
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Able to complete their own job |
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Complete the job, however with difficulty or lower efficiency/productivity |
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Able to work, but require accommodated duties. |
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Able to work, but require accommodated hours. |
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Is not currently able to complete the job |
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Anticipated return to work date: |
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Agreed accommodations |
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Duties agreed: |
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Work days: |
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Work hours: |
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Breaks required: |
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Tasks to avoid: |
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The employee did/did not trial the above agreed accommodations during the work visit. |
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Additional comments:
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NAME |
TITLE |
DATE |
CONTACT NUMBER |
SIGNATURE |
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CLIENT |
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THERAPIST |
INHERENT JOB ANALYSIS
Physical Demands (where O = Occasionally (<1/3); F= Frequently (1/3 - 2/3); C = Constantly (<1/3)) |
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(denotes if the item was assessed during the work visit) |
General observations (Time/Reps/Loads/Distance |
Frequency throughout the day |
Job Tasks (state number as listed above) |
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O |
F |
C |
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Baseline requirements |
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Standing |
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Sitting |
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Walking (even/uneven terrain) |
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Standing (Static/Dynamic) |
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Endurance |
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Climbing Stairs |
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Step ladders |
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Scaffold |
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Platform |
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Squatting |
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Crouching |
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Kneeling |
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Crawling |
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Trunk Rotation |
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Overhead reaching |
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Forward reaching |
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Static load |
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Heavy/repetitive lifting |
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Ground to waist |
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Waist to shoulder |
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Shoulder to above shoulder |
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Heavy/repetitive carrying |
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Repetitive pushing/pulling |