Attachment A WORK RESTRICTIONS/LIMITATIONS

A. NO WORK RESTRICTIONS B. RESTRICTIONS B1 NO HAZARDOUS MACHINERY Primarily for individuals having visual defects, diabetes, heat disease or hand and arm disabilities which increase the hazard of working with machinery such as rotary saws, punch presses, power trucks and cranes. LIMITED LIFTING For individuals with various disabilities such as back injures, deformities and hernia. GROUND LEVEL WORK ONLY For individuals susceptible to dizziness from any cause or having deformities or limitations of the extremities which prevent working on such fixtures as ladders, scaffolds and cranes. AVOID CHEMICAL FUMES For selected individuals with chronic bronchial conditions, hay fever or asthma, who should be restricted from occupations such as dry grinding, sandblasting and spray painting. AVOID SKIN IRRITANTS For individuals who are found to be sensitive to such irritants as paints, solvent, thinners, oils, greases, fuels, coolants, etc. LIMITED WALKING OR STANDING For individuals with such disabilities as back lesions, varicose veins, lower extremity disabilities and hear disease. LIMITED NOISE EXPOSURE For individuals with chronic ear conditions, partial deafness or nervousness, who may have these conditions aggravated by exposure to sound levels or high intensity such as those associated with motors, speed hammers, band saws, riveting and tumbling mills. VISUAL WEAKNESS For individuals with less than perfect vision whose defect may deter this individual from being transferred to a job requiring good vision such as driving vehicles, reading instruments and dials and operation hazardous machinery. OTHER RESTRICTIONS Other limitations to be specified in each case. EMPLOYEE RESTRICTIONS/LIMITATIONS Walk Standing Sitting Other Climbing Bending / Twisting Carrying Pushing/ Pulling Lifting Operating motor vehicle _____________________________________________________ Medication ___________________

B2 B3

B4

B5

B6

B7

B8

B9

Range of Motion ________________________