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DocuSign Envelope ID: Al E64657- B4BC- 4CBD- BBDE- 98475BE11255 <br />Fit For Duty Testing As Part Of A Return To Work ( "RTW ") Program To Include: <br />WorkSTEPS will be conducting Fit - for -Duty (Post -Injury RTW) Tests on existing employees to include the <br />following: <br />• Any reported injury, illness, or condition that gives the employer reasonable belief that the <br />employee's ability to perform essential job functions will be impaired or create a direct threat to <br />health and safety. <br />• This category may also include testing at the request of the employer because, although there has <br />been no formal injury or medical condition reported, the employer has observed current <br />performance problems or has received reliable reports of performance problems indicating that the <br />employee may not be able to perform essential job functions, or may pose a direct threat to the <br />health and safety of the employee or others. <br />• Even if the employee has fully "recovered" from injury or illness and no longer considers him or <br />herself "injured", for documentation purposes the test should be identified as a "post- injury" fit for <br />duty, or an injured worker, because that was the trigger for the test. <br />• When testing an employee post -injury or illness the provider will: <br />• Use the WorkSTEPS Fit for Duty Physical Capacity Consent Form <br />• Use the WorkSTEPS Post Injury Fit for Duty Medical History Interview <br />• Not perform "routine" medical measures, including heart rate and blood pressure, that are <br />not related to the injury or condition for which the employee is being seen, or that are not <br />contributing to a job related functional deficit. <br />• Not perform the standard "baseline" tests such as step test, Sorenson's or grip if they are <br />not related to the injured area. <br />• Perform only the dynamic lift postures that are considered qualifying criteria. <br />• Perform any and all standard job specific tasks for the position, and expand to include <br />any additional essential function tasks that could be impacted by their injury or condition. <br />Representative /Title <br />Date <br />WorkSTEPS Representative /Title Date <br />0 <br />