This is a confidential form and will be submitted by the requesting employee directly to his or her supervisor to complete workplace information.
Immediate Supervisor: Complete Sections 1 and 2; give this form with the employee’s up-to-date job description to the employee (see samples provided for Foresters and Forest Technicians). Once final completed form is returned, the supervisor will send to the Human Resources Office. Employee: Have your health care provider review and complete this form. Return the completed form to your supervisor before you return to work. Health Care Provider: Please complete Section 3 of this form and return it to the patient.
SECTION 1 – Employee Information
Employee Name:	Position Title:	Forest Technician
Agency:	Virginia Department of Forestry	Email:
Date Condition Began:	No. of Hours/Work Day:	10
Treating Physician:	Phone No.:
SECTION 2 – Physical Demands of Position
Make the appropriate entry for each of the following items to describe the extent of the specific activity performed by this employee during the course of a typical work period:
Job Duty/Task	None (0%)	Occasional (1%-33%)	Frequent (34%-66%)	Constant (67%-100%)
1. Sitting
2. Standing
3. Walking
4. Bending Over
5. Climbing
6. Reaching Overhead
7. Kneeling
8. Pushing or Pulling:
a) With Legs
b) With Arms
c) With Body
9. Lifting or Carrying:
a) 10 lbs. or less
b) 11 to 25 lbs.
c) 26 to 50 lbs.
d) 51 to 75 lbs.
e) 76 to 100 lbs.
f) More than 100 lbs.
10. Repetitive Use of Foot Control:
a) Right Only
b) Left Only
c) Both
11. Repetitive Use of Hands:
a) Right Only
b) Left Only
c) Both
12. Simple/Light Grasping:
a) Right Only
b) Left Only
c) Both
13. Firm/Strong Grasping:
a) Right Only
b) Left Only
c) Both
14. Is employee required to drive a car?	Yes	No
If yes, describe:	pickup truck and transport for bulldozer
15. Is employee required to operate heavy equipment?	Yes	No
If yes, describe:	bulldozer for firefighting
16. Is employee exposed to dust, gas or fumes?	Yes	No
If yes, describe:	when fighting fires
17. Is employee exposed to marked changes in temperature or humidity?	Yes	No
If yes, describe:	works outdoors frequently and is going in and out of air conditioning
Comments:
Works four 10-hour days. Works overtime and odd hours for emergency response as needed. Primary emergency response
is during the spring and fall fire seasons.
Supervisor Name (Print)	Supervisor Signature	Date
SECTION 3 – Physician Authorization
Complete the appropriate box below and provide comments as necessary:
The employee is able to work a full, regular schedule with no restrictions, beginning	(date).
I release the above employee to this position as described above.
I release the above employee to this position as described above with the following restrictions, beginning
(date):
The medical rationale for this is:
I am unable to release the above employee to this position as described above.
The medical rationale for this is:
Next Appointment is Scheduled for:
Physician Name (Print)	Physician Signature	Date