-- • JX» -TUe 7£YM. Ci2kx$T o\ CJLffV/VflC MfeBLS MM €r^ VtfU'" "°° 0U&"/*C NGc/t i fououMfr- R^sd/vs fteiocJ : A?i?eiUMt]s HBAum summaw MfeAfteD td tkU noi\m ju &yi\\q>\t# l . 55. AffetuiuT 2>a/£i/e TVfA-rrt£ hw commute comtro" r«u 0 KeftelW £>EOM£ UAJDefL PeKJA-LTY OF ?£/20U£/ THtfrUb fo£&0\*}G- ZTKTEnQJU /bOO A5C£fcrfcr YARDS NO HUMIDITY EXTREMES NO LIFTING > LBS. NO EXPOSURE TO ENVIRONMENT POLLUTANTS 10.NO BENDING AT WAIST NO WORK WITH CHEMICALS OR IRRITANTS 11.NO REPETITIVE SQUATTING NO WORK REQUIRING SAFETY BOOTS 12.NO CLIMBING NO WORK AROUND MACHINE WITH MOVING PART 3.LIMITED SITTING 26 .NO WORK EXPOSURE TO LOUD NOISES .NO REACHING OVER SHOULDER DISCIPLINARY PROCESS (CHECK ONE) A\ NO RESTRICTIONS B.) CONSULT REP OF MENTAL HEALTH DEPT BEFORE TAKING DISCIPLINARY ACTION C/ CONSULT REP OF MEDICAL DEPARTMENT BEFORE TWING DISCIPLINARY ACTION INDIVIDUALIZED TREATMENT P! ICK ALL TTHAT APPLY) A. NO RESTRICTION MENTAL HEALTH REPRESENTATIVE REQUIRED B. MEDICAL REPRESENTATIVE (REQUI VI. TRANSPORTATION RESTRICTIONS (CHECK ONE) X A. NO RESTRICTION C. WHEELCHAIR VAN B. EMS AMBULANCE D. MULTI-PATIENT VEHICLE(MPV) DAVE PA 07/20/2012 j< rwt fr-c PRINTED NAME AND TITLE OF REVIEWER DATE SIGNATURE OF REVIEWER