Current Progress
7/9

Please ensure section 7 is completed by the employee’s supervisor.

If you are not the plan member's supervisor, you can download this section and give it to the supervisor to complete. You can also attach the completed supervisor's statement here before submitting this claim, if available.

Completed by:

In the appropriate column, please specify the frequency and or weight for which the following activities are regularly performed:

  • Infrequent = 0-33% of the workday
  • Frequent = 34-66% of the workday
  • Constant = 67-100% of the workday

PHYSICAL ACTIVITIES

Activity
Walking
Sitting
Standing
Driving/Operating machinery
Climbing up and down the stairs
Does the employee's occupation require repetitive movements?

Lifting
0-10 lb.
11-20 lb.
21-50 lb.
51-100 lb.
100+ lb.

Pushing / Pulling
0-10 lb.
11-20 lb.
21-50 lb.
51-100 lb.
100+ lb.
Does the plan member use a lifting device?

COGNITIVE ACTIVITIES

Activity
Understanding and memory (Understanding and remembering instructions)
Sustained concentration (Maintaining attention and concentration for extended periods)
Social interaction (Interaction with co-workers and/or the general public)
Adaptation and multitasking (Response to frequent changes, juggle tasks and prioritizes)
Meeting deadlines (The work involves time pressure and deadlines)
Responsibility and accountability (Errors in judgement or attention can have significant consequences)

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