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Currency [0]/Explanatory TextB5Explanatory Text 0 : Followed Hyperlink 1Good6Good  a2 Heading 1B Heading 1 I}O3 Heading 2B Heading 2 I}?4 Heading 3B Heading 3 I}235 Heading 44 Heading 4 I}6( Hyperlink 7InputpInput ̙ ??v 8 Linked CellF Linked Cell } 9Neutral<Neutral  e"Normal :Noteb Note   ;OutputrOutput  ???????????? ???<$Percent =Title1Title I}% >TotalHTotal OO? Warning Text: Warning Text XTableStyleMedium9PivotStyleLight16`KSheet1Y~Sheet2Sheet3 {bLift and Carrya. less than 10 poundsb. 10-20 poundsc. 20-50 poundsd. 50-100 poundse. over 100 poundsor more800 Connecticut BoulevardWORKER STATUS REPORTEast Hartford, CT 06108T: 860-256-3400F: 860-291-9875&To Be Completed By Attending PhysicianEmployee Name (Last)(First)Social Security NumberEmployer DepartmentFacilityUnitAddress Initial VisitFollow-up Visit(Diagnosis/Condition (Brief Explanation): ICD-9 Code:#Evidence of pre-existing condition:! Yes No (If yes, explain)  J Injury/Illness casually related to worker s employment: Yes No;< FG Current Treatment Plan ABased on my assessment and treatment of this injury, I recommend:P Worker can return to work on ____ / ____ / ______ with no limitations. o Worker can return to modified work on ____ / ____ / ______ with the following functional limitations. /1. In a 8 hour workday, worker can stand/walk:5. Weight Handling Frequency(Hours at one time)Number per/hour 6-8  4-6  2-4  0-2 )2. In an 8-hour workday, worker can sit: No restrictions (Total hours during day)+3. In an 8-hour workday, worker can drive: No restrictions  1-3 (Minutes at one time) Use of left hand for repetitive: 30-60  10-30 Claim#(Circle)Date of Visit:___/___/____Date of Injury:___/___/____10-151-10 such as operating foot controls:*7. Use foot/feet for repetitive movement, Yes No   "Other Instructions or Limitations:Twist: 4. Bend:Squat:ClimbReach:. Not at all Occasionally Frequently  "# 9If on medication, will medication restrict the employee'sability to work safely? If yes, explain:Further treatment is needed:Follow-up appointment date:' These limitations are in effect until % Single grasping Fine manipulation  I He/she may not return to work until reevaluated here on ____/____/_____  He/she may return to modified work as shown above and is to be reevaluated by the specialist listed below on ____/____/_____. d He/she may not return to work until reevaluated by the specialist listed below on ____/____/_____.  Physician name  Non Physician provider name Specialty Appt. date:Provider name (print)Provider locationProvider's signatureDate License No.& Single grasping Fine manipulation   Pushing & Pulling $AUTHORIZATION TO RELEASE INFORMATIONInjured worker's signatureDate:'6. Use of right hand for repetitive: ^or the insurance company(if any) responsible for paying my Worker's Compensation claim and my /FAX OR SEND COMPLETED COPIES OF THIS REPORT TO:Time In: Time Out:fI hereby consent to the release of the above information to Gallagher Bassett Services, Inc. the payer Gallagher Bassett Services, Inc.Lemployer (91Ʒ CT State University - Confidential FAX No. (959) 255-8790. 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The application is responsible for updating this value after each revision. DocumentLibraryFormDocumentLibraryFormDocumentLibraryForm Oh+'0HPh Administrator Rivera, Norma (Human Resources)SummaryInformation( %DocumentSummaryInformation8*CompObj6lMicrosoft Excel@L?f@A@'$ ՜.+,D՜.+,0 PXx  GAB RobinsNorth America Sheet1Sheet2Sheet3  Worksheets@*2Zv7display_urn:schemas-microsoft-com:office:office#EditorOrder7display_urn:schemas-microsoft-com:office:office#Author$_ip_UnifiedCompliancePolicyUIAction&_ip_UnifiedCompliancePolicyProperties Rivera, Norma (Human Resources)258600.000000000 Rivera, Norma (Human Resources) F Microsoft Excel 2003 WorksheetBiff8Excel.Sheet.89q