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GBEE Modified Work Program Form

To be completed by attending medical practitioner.

The Fort McMurray Public School District has a Modified work program and will adhere to the restrictions you place on our employee. It is to every ones benefit to be able to maintain productive employment.

Performance Limits Agreement

I UNDERSTAND THAT THE FOLLOWING LIMITS HAVE BEEN SET FOR ME.  I AGREE NOT TO EXCEED THESE LISTED LIMITS.

PERFORMANCE LIMITS:

BENDING:  
CLIMBING:  
CRAWLING:  
EQUIPMENT (operating)
HEIGHTS  
KNEELING:  
LIFTING:  
PULLING:  
PUSHING:  
SITTING:  
SQUATTING:  
STANDING:  
STOOPING:  
TWISTING:  
VEHICLE: (operating)
WALKING:  
OTHER:  

SHOULD ANY CHANGE BE REQUIRED FROM THESE ESTABLISHED LIMITS, A NEW FORM MUST BE COMPLETED.


SIGNATURES: 


MEDICAL PRACTITIONER:  ________________________________________   DATE: ________________

CLINIC/HOSPITAL NAME: _________________________________________________________________

EMPLOYEE:  _____________________________________________________  DATE:  _______________


SUPERVISOR/SAFETY:  ____________________________________________  DATE:  _______________

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