work plan for soil remediation, sampling and analysis plan, site ...
work plan for soil remediation, sampling and analysis plan, site ...
work plan for soil remediation, sampling and analysis plan, site ...
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*c= OH31 Remediation\m Services Corp.ASUUdUYdOIDICForm 0085H & S Dept.2195INJURY/ILLNESSSTATUS REPORTEmployee Social Security No.Home AddressPhoneJob TitleHome DivisionDate of Injury/Illness Description of Injury/IllnessAUTHORIZATIONTO RELEASE INFORMATION.:.‘.I hereby authorize all physicians, hospitals, clinics <strong>and</strong> all persons to discuss with, <strong>and</strong> release to OHM Remediation ServicesCorp. <strong>and</strong> its authorized agents, any in<strong>for</strong>mation or copies thereof acquired in the course of my examination or treatment <strong>for</strong>the injury identified above. This authorization shall not extend to any other medical condition, past or present, unless the sameis causally or historically relevant or related to the injury referred to above.Employee SlgnatureDatePHYSICIAN OR MEDICAL PERSONNEL TO COMPLETE REMAINDER OF FORMWORK STATUS0 l3nptoyw m8y return to worlc with no IImItatIonsPata0 Employee may return to worlc onPatewith llmltatlona Indicated. Thesa mstrlctl0n.a am inl ffecl IJmll or until ReevefuatlonPateonoat.Em~l~mwworN - hours In a <strong>work</strong> day.0 tnployw Is totslfy Incapacitated at thls tlmrpalent witI be rwvuueted onourDEGREE0 Sedentary Work. Uftlng 10 pounds maximum<strong>and</strong> occasiomlly liftlng an&or unying such articlesU docket& ledgers, <strong>and</strong> small tools. Although asodent8ry job la deflned as one which invofveeafttlng, a cerlain amount of welktng JIM st<strong>and</strong>lng isoften necesury in canying out job duties. Jobe are8edontary If walking <strong>and</strong> st<strong>and</strong>lng are requimd onlyaturtonafly <strong>and</strong> other sedennuCy criteri8 am met.0 m Work. Uftlng 29 pounds maximum withfrequent liftlng &Or carrying of objects weighingup to 10 pounds. Even though the weight Ilfted maybe only a negligible amount. a job is in this categorywhen it requirea walking or st<strong>and</strong>lng to a significantdegroo or when it involves rittfng most of the timewith a degree of pushing <strong>and</strong> pulling of arm <strong>and</strong>lorleg controls.0 mum Work. Uftlng 59 maximum with frequentllftlng <strong>and</strong><strong>for</strong> carrying of objects weighing up lo 25poun-.0 Heevy Woh Liftlng 199 pounda maximum withfr$tm llttlltt~stior carrying of oblects weighlng.0 Very Heavy Work. Uftlng oblects In ucoss of199 pounds with frequent llftlng <strong>and</strong>/or canying ofoblocts weighing 59 pounds or more.LIMITATIONS1. lho Employee may:a St<strong>and</strong>fwalk0 None 0 14hows0 44houn QMltounlhcsit0 14houn q 36houls0 5ahounorlvo0 1-3houn 034hOUf80 s-ahotm2 E%Weerruyuaehmda<strong>for</strong>remt~0 SInglo g-ping 0 Puehlng 6 pulling0 Fine manipuletlon3. Employee mey use feet <strong>for</strong> mpmtltlve movementa8 in operatlng foot controfr0 Yea 0 No4. Employoa is able to:Frequenty Occaslorufly Not all Alla Bend-0 0 0b. squat-o a 0c. Cllmb.,O 0 0DiagnosisTreatmentOther iiPHYSICIAN’S REPORT-. Whom0 Referred to c.om?any physician0 Employee referred/admitted to:AddressPhone:Jate of this ReportPhysician’s NamePhysician’s Signature .PrintAddressPhoneWhit0 - Company COPYCanay - Clime CopyPlnk - &nployee COPY 16406 U.S. Route 224 E. l P.O. Box 551 l Findlay, OH 45839-0551 l (419) 456064DateTime
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