Job Demands

Your physiotherapist has been asked by WorkSafeBC to:

Outline the physical demands of your job and confirm these job demands with your employer.
Assess your ability to safely perform these job demands
Confirm the availability of modified job duties/hours

To assist your physiotherapist in completing these tasks, please provide the following information:

Name*

First Last

Employer

Job Title

Shift Hours/Days

Supervisor Name and Phone Number*

Please provide a brief description of your job:

Sitting

Description

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Standing

Description

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Walking

Description

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Running

Description

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Uneven Surfaces

Description

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Squating/Crouching

Description

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Kneeling

Description

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Stairs/Ladders

Description

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Twisting/Rotation

Description

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Lift Below Waist

Description

Indicate the heaviest weight handled*

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Lift Waist to Shoulder

Description

Indicate the heaviest weight handled*

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Lift Above Shoulder

Description

Indicate the heaviest weight handled*

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Two Hand Carry

Description

Indicate the heaviest weight handled*

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Push/Pull

Description

Indicate the heaviest weight handled*

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Grip/Handling

Description

Indicate the heaviest weight handled*

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Reaching - Waist Level

Description

Sustained
Repetitive

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No

Reaching - Crown Level

This field is hidden when viewing the form

Section Break

Description

Sustained
Repetitive

Section Break

How often do you Perform the Activity?*

Are You Currently Able To Do This Actvity*

Yes
No