Used by employer of record to prepare a written job description for a light-duty job, transitional, modified duty job, or alternative job when an injured worker is unable to work due to an industrial injury or occupational disease. The form includes a description of the job tasks, machinery, tools, equipment and personal protective equipment used, and the physical demands of the job. After completing the employer's job description form, the employer gives it to the injured worker's doctor for review and approval.

Used by Spanish speaking health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans.

Utilizado por proveedores de cuidado de la salud que hablan español para indicar la condición actual del trabajador lesionado, restricciones físicas, certificación de tiempo perdido y planes de tratamiento.

Used by health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans. To print an APF, click on the title of the form in the box above.

Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims.

Used by occupational and physical therapy providers as an optional reporting format for a Performance-based Physical Capacities Evaluation.

The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker.

This form is required by L&I before they can process any changes to the ownership, physical or mailing address.

IME Doctor’s Estimate of Physical Capacities: For use by independent examiners when asked to estimate physical capacities as part of an IME requested by the department.

Used by employers rehiring developmentally disabled workers after an industrial injury. This form requests preferred worker status and shows the physical demands of the work to be performed by the worker. The Preferred Worker Employer's Job Description (F280-022-000) should be attached.

Used by vocational rehabilitation counselors (VRCs) to document the physical demands of jobs.

This form is used by applicants applying for a charter boat operators license to have completed by a physician for an operators license