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Contents : ESTIMATED PHYSICAL CAPABILITIES SECURITY SERVICES AND SUPERVISORS Name of Physician: Name of Employee: Note: Important Information on Reverse Instructions: If the employee is found to be 50% or less disabled please complete this form based on your estimation of his/her physical capabilities. 1. Medical Diagnosis: 2 a. In an eight hour workday how many hours can this employee: (please check appropriate boxes) Sit 1 2 3 4 5 6 7 8 Continuously Stand 1 2 3 4 5 6 7 8 Continuously Walk 1 2 3 4 5 6 7 8 Continuously b. In a given day for how many hours can this employee sit stand and/or walk in combination 4 6 8 10 12 14 16 With Rests With Rests With Rests 3. Other Capabilities: (please check appropriate boxes) Never Occasionally Frequently Continuously Lift 0 10 lbs 11 20 lbs 21 50 lbs 51 100 lbs Carry 21 50 lbs 51 100 lbs Bend Squat Climb Run Reach above shoulder level Operate a motor vehicle 0 10 lbs 11 20 lbs Upper Extremities: Which hand is dominant Right Left Can this employee perform repetitive actions such as: Simple Pushing & Fine Grasping Pulling Manipulation Yes No Yes No Yes No Right Left Yes No Yes No Yes No Lower Extremities: Use of feet/legs for repetitive movement as in operation of foot controls and motor vehicles: Right Left Simultaneous Extremity Extremity Yes No Yes No Yes No 4. Work Environment Restrictions Can this employee: Be exposed to marked changes in temperature and humidity Be exposed to unprotected heights Be around moving machinery Yes No Yes No Yes No 5. Other Restrictions Can this employee restrain combative clients Does this employee have any visual or hearing impairment requiring accommodation If Yes please explain: Yes No Yes No 6. Based on your examination(s) of this employee are there any known problems of a general nature including any medications prescribed for the diagnosis listed that would interfere with this employee returning to work Yes No If Yes please explain: 7. When in your estimation will this employee be ready to return to full duty Comments: Physician s Signature (3/93) Telephone Number Date Date LIMITED DUTY PROGRAM New York State and Council 82 AFSCME AFL CIO negotiated a Limited Duty Program as part of the employer provided benefits associated with workers' compensation disabilities in the 1991 95 agreements. This program allows employees in the Security Services and Security Supervisors Units who have been disabled temporarily due to occupational accidents to return to work prior to full recovery and work in assignments that meet both the needs of the agency and the medical limitations of the employees. Employees benefit from this Program by returning to work and becoming productive more quickly thus enhancing the recuperation process. Agencies benefit from this Program because they have the services of employees who would otherwise be unable to return to work. When an employee's level of disability is classified at 50% or less (mildly or moderately disabled) the employee is qualified for a limited duty assignment. The agency will use the information provided on this form by the evaluating physician to design a limited duty assignment that is consistent with the employee's limitations and capabilities. Usually an assignment will be given to an employee in blocks of time of no more that 45 days each until the employee has fully recovered and returns to his/her regular assignment. During the period of limited duty the employee will be expected to provide period

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