Report Type (Check One Only)

/ / Activity-related Soft Tissue Disorder
(ASTD) Job Site Visit Report (continued)
performed by an occupational therapist
Worker last name / First name / Middle initial / WorkSafeBC claim number
/ / Activity-related Soft Tissue Disorder
(ASTD) Program Job Site Visit Report
performed by an occupational therapist
CLAIMS CALL CENTRE
Phone 604 231-8888
Toll-free 1 888 967 5377
M–F, 8:00 a.m. to 4:30 p.m. / FAX
604 233-9777
Toll-free 1 888 922-8807 / MAIL
WorkSafeBC
PO Box 4700 Stn Terminal
Vancouver BC V6B 1J1 / Number of pages submitted

Report type (check one only)

ASTDJSVIN: ASTD Initial Job Site Visit / ASTDJSVSB: ASTD Subsequent Job Site Visit
Date of report (yyyy-mm-dd) / Date of site visit (yyyy-mm-dd) / Date of report (yyyy-mm-dd) / Date of site visit (yyyy-mm-dd)

Worker and claim information

Worker last name / First name / Middle initial / WorkSafeBC claim number
Area(s) of injury accepted on this claim / Date of job site visit (yyyy-mm-dd)

Provider information

Company name / Payee number
Contact name / Contact’s direct extension/phone number (if applicable)
Mailing address (include address, city, province, postal code) / Company phone number (include area code)
Fax number (include area code)

Employer and job information

Company name
Work site address / City / Province / Postal code
Company phone number (include area code) / Fax number (include area code)
Contact name / Contact job title
Contact phone number (include area code) / Worker occupation
Pre-injury job attachment status (check one only)
Job attached Not job attached
Not yet confirmed / Usual pre-injury work schedule (days and hours)
Days per week Hours per day
Comments (if applicable)

Participants attending the job site visit

Include participant names and roles

Purpose of job site visit

Brief review/confirmation of job demands — Refer to job demands table in the appendix for additional details,
if applicable. Delete the appendix if not applicable to this visit.
Review possible job modifications
Explore return-to-work (RTW) opportunities
Graduated-return-to-work (GRTW) support (e.g., coaching, shadowing)
Other (please specify)
Job site visit findings
Additional comments
Recommendations

Report prepared by

Name(s) of report writer(s)

Personal information on this form is collected for the purposes of administering a worker’s compensation claim by WorkSafeBC in accordance with the Workers Compensation Act and the Freedom of Information and Protection of Privacy Act. For further information about the collection of personal information, please contact WorkSafeBC’s Freedom of Information Coordinator at PO Box 2310 Stn Terminal, Vancouver BC, V6B 3W5, or telephone 604 279-8171.

(13/07) Page 1 of 5 / 83D201
/ / Activity-related Soft Tissue Disorder
(ASTD) Job Site Visit Report (continued)
performed by an occupational therapist
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 / 5 times an hour for 4 hours consecutively each shift or occasional / NA / Stacking boxes of produce in back of delivery truck. Worker can ask for help if products weigh > 50 lb
Lift floor to waist
Lift waist to shoulder
Lift — other (describe)
Front carry
Right carry
Left carry
Push
Pull
Sustained grip
Repeated grip
Sustained pinch
Repeated pinch

Add or delete rows as appropriate to the worker’s injury-specific job demands.

Physical demand / Frequency / Duration (sustained/intermittent) / Distance / Height / Task description, Comments
Example:
Reaching above shoulder / Rare / 3 minutes sustained / NA / 8-ft ceilings / Reaching overhead to change light bulbs.
Step-ladder is available if needed.
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

Environmental factors

Additional comments (if applicable)

National Occupational Classification (NOC) strength category definitions / Dictionary of Occupational Titles (DOT) frequency descriptors
Limited / Work activities involve handling loads 0–5 kg (11 lb)
Light / Work activities involve handling loads 5–10 kg (22 lb)
Medium / Work activities involve handling loads 10–20 kg (44 lb)
Heavy / Work activities involve handling loads ˃ 20 kg (44 lb)
/ Frequency / % of workday
Never / 0%*
Rare / ˂ 5%*
Occasional / 5–33%
Frequent / 34–66%
Constant / 67–100%
* While not a defined DOT descriptor, “never” and “rare” are commonly used to describe activities which occur < 5% of the workday, or not daily.
(13/07) Page 1 of 5 / 83D201