Common use of Waist to Shoulder Clause in Contracts

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left hand(s): Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes No Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right hand(s): Left Hand Gripping Gripping Pinching Pinching Other (please specify): Right Hand Gripping Pinching Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes No Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right Hand(s): Left Hand Gripping Gripping Pinching Pinching Other (please specify): Right Hand Gripping Pinching Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left hand(s): Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Yes No (please specify): Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Yes (please specify): No Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left hand(s): Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes No Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left hand(s): Left Hand Gripping Pinching Other (specify): Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit transit: Yes No Ability to drive car car: Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right hand(s): Left Hand Gripping Gripping Pinching Pinching Other (please specify): Right Hand Gripping Pinching Other (please specify): APPENDIX B – ABILITIES FORM Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Yes No Yes No Repetitive movement of (please specify): Ability to drive car Yes Yes No Nocar

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Yes No (please specify): _ Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes Yes Ye s Ye s No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: 16 Travel to Work: Ability to use public transit Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): APPENDIX B – ABILITIES FORM Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes No Yes No NoRepetitive movement of (please specify): above shoulder activity: exposure to:

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left hand(s): Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit _ _ Ability to drive car Yes No Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit _ Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left hand(s): Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Yes No repetitive movement of (please specify): Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left hand(s): Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit _ _ Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand(s): Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit ______________________ Ability to drive car Yes No ______________ Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Draft Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): MEDICAL CERTIFICATE CONFIDENTIAL Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left hand(s): Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Gripping Pinching Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left Hand(s): Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: Ability to use public transit Ability to drive car Yes Yes No No

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify): Stair Climbing: Full abilities Up to 5 steps 6 - 12 steps Other (please specify): Use of hand(s):Left hand(s): Left Hand Right Hand Gripping Gripping Pinching Pinching Other (please specify): Other (please specify): Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: Chemical exposure to: Travel to Work: of repetitive movement shoulder activity: Ability to use public transit Yes No (please specify): Ability to drive car Yes Yes No No