KEPCO Clinic

P.O. Box 11827, Al Braka, Al Ruwais, Abu Dhabi, U.A.E., Tel. No. +971 2 8092119 Mobile. No. : +97156 6432821; E-mail Address: kepcoclinic@kepco.co.kr

SICK LEAVE / FIT TO WORK

Medical Record No.: Patient Name: DOB/Age: Nationality: Company: Insurance:

Sex:

Date: To whom this may concern: This is to certify that Mr. / Ms. came to KEPCO Clinic for check up on the employee: may return to his/her regular job without restrictions. be able to return his/her light duties**. cannot perform any duties. needs rest for ( ) day/s from ( FAC / MTC ) ( RWC ) ( LTI ) after evaluation,

**List of light duties: refer to the attachment. (Doctors note)

Thank you.

KEPCO Clinic Physician

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KEPCO Clinic

P.O. Box 11827, Al Braka, Al Ruwais, Abu Dhabi, U.A.E., Tel. No. +971 2 8092119 Mobile. No. : +97156 6432821; E-mail Address: kepcoclinic@kepco.co.kr

SICK LEAVE / FIT TO WORK

Medical Record No.: Patient Name: DOB/Age: Nationality: Company: Insurance:

Sex:

A List of Light Duties

Using small bench tools or small power tools (able except both upper limb injury) Inspecting and sorting produce (able except eye injury) Sorting light materials (able)

Answer telephones (able)

File paperwork (able)

Shred documents (able)

Assembling small parts (able)

Complete safety training (able except lower limb injury)

Driving vehicle on roads (unable)

Update MSDS manuals (able except upper limb injury)

Nailing (able except upper limb injury)

Sweeping (able)

Security guard (able except lower limb injury) Paint aisle markings (able except both upper limb injury) Inventory parts, supplies, and/or tools (able)

Wash company vehicles (unable)

Mow lawns with riding lawn mower (unable)

Update safety bulletin board (able except lower limb injury)

Pick up trash in yard and lot (able)

Clean tools (able except upper limb injury)

Inspect fire extinguishers & eye washes (able)

Apply ice melter during winter months (unable

Replenish first aid cabinets (able)

Inspect flooring for need for maintenance or cleaning (able) Create or re-write evacuation maps (able except upper limb injury) Picking fruits and vegetables (bending, squatting) (unable)

Perform assembly (able) Complete a safety inspection (able except lower limb injury) Drive a fork truck (unable)

Painting with a brush (able except both upper limb injury) Pushing or pulling lightweight carts or wheelbarrows (unable) Off road operation of trucks, tractors or construction equipment (unable) Operating an air hammer (unable)

Sort & deliver mail (able)

Work in tool room (able)

Make telephone calls / answer telephones (able)

Order supplies (able) Shipping (labeling & wrapping) (able except upper limb injury) Train new employees(able)

Weeding or hoeing (able except both upper limb injury)

Do light housekeeping and dusting (able) Perform quality control inspections(able except lower limb injury Any light work that does not conflict with restrictions set forth by a physician

Drive a vehicle, run errands (unable)

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