Return-to-Work Support Services (RTWSS)
Job Demands Analysis Report
Number of pages
submitted
6
Report
Date of report (yyyy-mm-dd)
Date of visit (yyyy-mm-dd)
Worker and claim information
Worker’s last name
First name
Date of injury (yyyy-mm-dd)
Middle initial
WorkSafeBC claim number
Claim owner
Area(s) of injury accepted on this claim
Provider information
Company’s name
Payee number
Contact’s name
Mailing address
Contact’s direct extension/phone number
Company’s phone number
(include address, city, province, postal code)
Fax number
(if applicable)
(include area code)
(include area code)
Employer and job information
Company’s name
Worksite address
City
Company’s phone number
Contact’s name
Contact’s phone number
Postal code
(include area code)
Contact’s job title
(include area code)
Pre-injury job attachment status
Job attached
Not yet confirmed
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Fax number
(include area code)
Province
(check one only)
Not job attached
Worker’s occupation
Usual pre-injury work schedule
Days per week
Comments
(days and hours)
Hours per day
(if applicable)
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Return-to-Work Support Services (RTWSS)
Job Demands Analysis Report
Worker last name
First name
Middle initial
WorkSafeBC claim number
Participants attending the job demands analysis
Include participant names and roles
Job Demands Analysis findings
(see Appendix — Review of Job Demands for details)
Additional comments
Barriers to returning to work
(if involved with graduated return-to-work (GRTW) planning)
Recommendations
Report prepared by
Name(s) of report writer(s)
Signature(s) of writer(s)
Claims Call Centre
Phone 604.231.8888
Toll-free 1.888.967.5377
M–F, 8:00 am to 4:30 pm
Fax
604.233.9777
Toll-free 1.888.922.8807
Mail
WorkSafeBC
PO Box 4700 Stn Terminal
Vancouver BC V6B 1J1
WorkSafeBC collects information on this form for the purposes of administering and enforcing the Workers Compensation Act. That Act, along with the
Freedom of Information and Protection of Privacy Act, constitutes the authority to collect such information. To learn more about the collection of personal
information, contact WorkSafeBC’s freedom of information coordinator at PO Box 2310 Stn Terminal, Vancouver BC, V6B 3W5, or call 604.279.8171.
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Return-to-Work Support Services (RTWSS)
Job Demands Analysis Report
Worker last name
First name
Middle initial
WorkSafeBC claim number
Appendix — Review of Job Demands
Worksite description
Description of job tasks
Add or delete rows as appropriate to the worker’s injury-specific job demands.
Task 1
Task 2
Task 3
Critical job demands relevant to the accepted injury
Add or delete rows as appropriate to the worker’s injury-specific job demands.
Strength activities
Weight (lb)
Frequency
Distance
Task description, Comments
Example:
Lift floor to waist
Up to 50 lb
Occasional
(first half of the day)
NA
Stacking boxes of produce in the storage room. Worker can ask for help if products
weigh > 50 lb. Five times an hour for the first half of the day
Lift floor to waist
Lift waist to shoulder
Lift — other
(describe)
Front carry
Right carry
Left carry
Push
Pull
Sustained grip
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Return-to-Work Support Services (RTWSS)
Job Demands Analysis Report
Worker last name
Strength activities
First name
Weight (lb)
Frequency
Distance
Middle initial
WorkSafeBC claim number
Task description, Comments
Repeated grip
Sustained pinch
Repeated pinch
Add or delete rows as appropriate to the worker’s injury-specific job demands.
Physical demand
Frequency
Example:
Reaching above shoulder
Rare
Duration
(sustained/intermittent)
Distance
Height
Task description, Comments
3 minutes sustained
NA
8-ft ceilings
Reaching overhead to change light fixtures
Reaching above shoulder
Reaching below shoulder
Manual dexterity
Finger dexterity
Stooping — forward
bending in standing
Kneeling
Crouching
Sitting
Standing
Climbing, stairs/ladders
Walking
Forward bending in sitting
Crawling
Other
Tools and equipment used
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Return-to-Work Support Services (RTWSS)
Job Demands Analysis Report
Worker last name
First name
Middle initial
WorkSafeBC claim number
Environmental factors
Psychosocial factors (add or delete rows as appropriate)
Demand
Intensity*
Description/Comments
* Demand intensity: 1 = no requirement, 2 = Low requirement, 3 = Moderate requirement, 4 = High requirement
Degree of self-supervision required
Degree of supervision exercised
Deadline pressures (time pressures)
Attention to detail required
Performance of multiple tasks
Exposure to environmental stimuli
Need to work cooperatively with others
Exposure to emotional situations
Exposure to confrontational situations
Responsibility and accountability required
Reading literacy
Writing literacy
Numerical skills
Computer literacy
Verbal communication
Stress
Additional comments (if applicable)
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Return-to-Work Support Services (RTWSS)
Job Demands Analysis Report
Worker last name
First name
National Occupational Classification (NOC)
strength category definitions
Middle initial
WorkSafeBC claim number
Dictionary of Occupational Titles (DOT)
frequency descriptions
Limited
Work activities involve handling loads 0–5 kg (11 lb)
Frequency
% of workday
Light
Work activities involve handling loads 5–10 kg (22 lb)
Never
0%*
Medium
Work activities involve handling loads 10–20 kg (44 lb)
Rare
< 5%*
Heavy
Work activities involve handling loads > 20 kg (44 lb)
Occasional
5–33%
Frequent
34–66%
Constant
67–100%
* While not a defined DOT description, “never” and “rare” are commonly used
to describe activities which occur < 5% of the workday, or not daily.
Appendix — Photos (if applicable)
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