Status Report

EMPLOYEE'S FULL NAME: _________________________________________________

DO NOT INCLUDE MEDICAL DIAGNOSIS. If you need additional information, please contact Human Resources at 541-346-3159.

PLEASE CHECK APPROPRIATE STATUS (ONE ONLY
[ ] May return to regular job (complete items 6, 7 & 8) Date: __________________
[ ] May return to limited-duty (complete items 1-8) Date: _________________________
[ ] May not return to work (complete items 6, 7 & 8) Date: ___________________

1. In an ____ hour day, employee can: (circle duration for each activity)

Sit
1
2
3
4
5
6
7
8
Stand
1
2
3
4
5
6
7
8
Walk
1
2
3
4
5
6
7
8

2. Employee is able to: (circle capacity for each activity)

100% 66% + 34-65% 1-33% 0%
Bend No restriction Frequently Moderately Occasionally Never
Climb No restriction Frequently Moderately Occasionally Never
Crawl No restriction Frequently Moderately Occasionally Never
Push No restriction Frequently Moderately Occasionally Never
Pull No restriction Frequently Moderately Occasionally Never
Reach (above shoulder) No restriction Frequently Moderately Occasionally Never
Squat No restriction Frequently Moderately Occasionally Never

3. Use of Hands (Circle yes or no as it applies to each task)

Repetitive Action Simple Grasping Pushing/Pulling Fine Manipulation
Right
Yes
No
Yes
No
Yes
No
Yes
No
Left
Yes
No
Yes
No
Yes
No
Yes
No

4. Lifting Capabilities (Please circle)

100% 66% + 34-65% 1-33% 0%
Up to 10 lb. No restriction Frequently Moderately Occasionally Never
11 to 20 lb. No restriction Frequently Moderately Occasionally Never
21 to 50 lb. No restriction Frequently Moderately Occasionally Never
51 to 100 lb. No restriction Frequently Moderately Occasionally Never

5. Projected time needed for limited duty: ____ 3-7 days ____ 7-14 days ____ 2-4 weeks _____N/A

6. Date of next appointment: _____________________________________

7. Treating Physician Name: ______________________________________

8. Treating Physician Signature: __________________________________