Form 409-1

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