Form 23-B WC "Nh Workers' Compensation Task Analysis" - New Hampshire

What Is Form 23-B WC?

This is a legal form that was released by the New Hampshire Department of Labor - a government authority operating within New Hampshire. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2015;
  • The latest edition provided by the New Hampshire Department of Labor;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 23-B WC by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Labor.

ADVERTISEMENT
ADVERTISEMENT

Download Form 23-B WC "Nh Workers' Compensation Task Analysis" - New Hampshire

Download PDF

Fill PDF online

Rate (4.4 / 5) 36 votes
LAB 500
NH WORKERS’ COMPENSATION TASK ANALYSIS
In compliance with RSA 281-A:23-b, the employer with 5 or more employees must provide temporary
alternative/transitional work opportunities to all employees temporarily disabled by a work-related injury or illness.
Task is defined as one of the distinct activities that constitute logical and necessary steps in the performance of a job. A
task analysis, for the purpose of this section, is the evaluation of the physical requirements of each task of a particular job or
work assignment.
Employer
Employee
Telephone #
W.C. Insurer
EmployerAddress
Complete the following information to describe the employee’s job at the time of injury:
Job Title
Usual Job? Yes
No
General Description/Purpose
Department
Supervisor
Description of Tasks (use additional page as needed):
1 .
2 .
3.
4 .
5 .
Tools& Equipment
Describe Special Demands
PHYSICAL DEMANDS
Complete the following to show the maximum physical demand for all of the tasks listed above. For example, if Tasks
1 through 4 require no bending but Task #5 requires “occasional” bending, the overall job must be rated as requiring
occasional bending.
JOB REQUIRES:
JOB REQUIRES
Continuous
Frequent
Occasional
part of day
100%-67%
66%-34%
33%-1%
maximum lifting/carrying of
lbs
bending
frequent lifting/carry of
lbs
kneeling
squatting
WORK SCHEDULE:
climbing
standing
Number of hours/day
walking
Number of days/week
sitting
Does job require Repetitive Motions? (check if applicable)
reaching
wrist
elbow
shoulder
ankle
driving
Right
fine motor skills
Left
ATTACH JOB DESCRIPTION IF AVAILABLE
Completed by
Title
Date
23-b WC (9/2015)
LAB 500
NH WORKERS’ COMPENSATION TASK ANALYSIS
In compliance with RSA 281-A:23-b, the employer with 5 or more employees must provide temporary
alternative/transitional work opportunities to all employees temporarily disabled by a work-related injury or illness.
Task is defined as one of the distinct activities that constitute logical and necessary steps in the performance of a job. A
task analysis, for the purpose of this section, is the evaluation of the physical requirements of each task of a particular job or
work assignment.
Employer
Employee
Telephone #
W.C. Insurer
EmployerAddress
Complete the following information to describe the employee’s job at the time of injury:
Job Title
Usual Job? Yes
No
General Description/Purpose
Department
Supervisor
Description of Tasks (use additional page as needed):
1 .
2 .
3.
4 .
5 .
Tools& Equipment
Describe Special Demands
PHYSICAL DEMANDS
Complete the following to show the maximum physical demand for all of the tasks listed above. For example, if Tasks
1 through 4 require no bending but Task #5 requires “occasional” bending, the overall job must be rated as requiring
occasional bending.
JOB REQUIRES:
JOB REQUIRES
Continuous
Frequent
Occasional
part of day
100%-67%
66%-34%
33%-1%
maximum lifting/carrying of
lbs
bending
frequent lifting/carry of
lbs
kneeling
squatting
WORK SCHEDULE:
climbing
standing
Number of hours/day
walking
Number of days/week
sitting
Does job require Repetitive Motions? (check if applicable)
reaching
wrist
elbow
shoulder
ankle
driving
Right
fine motor skills
Left
ATTACH JOB DESCRIPTION IF AVAILABLE
Completed by
Title
Date
23-b WC (9/2015)