1996 CEC Associates, Inc. All rights reserved. No part of these materials may be reproduced without permission from CEC Associates, Inc., P.O. Box 987, Valley Forge, Pennsylvania, 19482. (610) 935-7560.

(1) Transition-to-Work Plan

Employee Name

Employee Address

Telephone:

Date:

Treating Professional: ________________________________________________

Address:

Telephone:

Summary of present treatment plan:

_________________________________________________________________

________________________________________________________________

_________________________________________________________________

Summary of Functional Capacities (See attached for comprehensive Functional Capacity Evaluation):

_________________________________________________________________

Functional Capacity Update:

Changes (as determined by the attending physician) in the Functional Capacities as of _______________(date).

________________________________________________________________________

_______________________________________________________________________

Changes (as determined by the attending physician) in the Functional Capacities as of _______________(date).

________________________________________________________________________

Start date of transition: _________________________

Projected # of weeks in transition: _________________________

Projected date of transition completion: _________________________

Employment Option:

_______________ Same job

_______________ Same job with accommodation

_______________ Different job

_______________ Different job with accommodation

Job Title: _________________________________________________________________

(2) Sample Job Content (Job Description) Form Based on the Essential Functions of the Job

Job Title: Mold Press Operator

Job Objective(s): To heat-cure ring seals per specifications and ensure 100% quality control

Essential Job Functions (functions essential to attaining the Job Objectives):

Places compound (unfinished ring seal) onto loading board and stripper plates; loads compound onto mold

Sprays lube over each mold using circular motion to ensure complete lubrication of

Operates (pushes button to hydraulically activate) mold press to ease bottom molds up into stripper plate and to close presses

Cleans flashing off molds; removes and inspects press

Job Standards (minimum qualifications needed to perform essential functions):

Repetitive fine manipulation; prolonged standing; able to lift loading board (23 lbs.) from shoulder height to above shoulder
Pushing/pulling (43 lbs. resistance) stripper plate and knockout table
Exposure to mold release mist and high temperatures; repetitive reaching, waist to shoulder level; ability to discern imperfections of seals; ability to read process and attribute charts; ability to count time spent on press; ability to generate attribute chart information; tolerance to work alone with minimum or no

Job Location (Place where work is performed): Mold Press Department

Equipment: Compound loading board; compound; stripper plate rings; lube (water and mold release solution); lube sprayer; attribute chart; heat press; air hose

(3) Transition Objective:

_________________________________________________________________

The objective should be stated in measurable terms. The objective must include precisely which job the employee is being readied for, the specific date by which the readiness preparation is intended to be achieved, and the job performance standards that will be expected. If an accommodation is involved, it needs to be specified in the objective.

A sample objective might look something like this:

To prepare {the employee named above} to be able to perform the job of Mold Press Operator. {The employee} will be able to perform, with or without a reasonable accommodation, each of the essential functions given in the Mold Press Operator Job Description (see attached). The transition-to-work plan sets the number of weeks to achieve readiness at 12 weeks. The plan includes incremental length-of-day durations and exertion levels (see attached). The output standard for parts produced per hour is set at 14, which is to be achieved incrementally over the 12 weeks prescribed in this plan. The spray gun used in this job will be suspended on a spring 8 inches above the employee's shoulder as he {she} stands before the mold.

CEC Associates, Inc.: Maintaining Employees and Productivity Through Disability Management Established 1983

CEC Associates, Inc.:
Maintaining Employees and Productivity
Through Disability Management
Established 1983