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DocuSign Envelope ID:6E9B5308-6677-4F2E-9268-29D6E1A4FD76 <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 /> i <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 /> i' <br /> employee may not be able to perform essential job functions, or may pose a direct threat to the fr <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 /> I' <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 /> DocuSigned by: <br /> b6VuLkA'f, 11/3/2015 <br /> nFZ�ooe®755�7�... <br /> Representative/Title Date <br /> DoL ��cu��Signed by: <br /> Puy Ga 10/22/2015 <br /> 48 Rlaa <br /> =a4 <br /> WorkSTEPS Representative/Title Date <br /> Revised 10/2015 9 <br />