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Get Work Status Report 2000-2025

TIAL WORK RESTRICTION [ ] Referred to __________________________ for ______________________________ Patient's Name ___________________________________ File # _____ Date of Injury ____________ This patient CAN PERFORM the indicated activities up to, but not to exceed, the indicated # of hours. Activity Must be Intermittent (5 min. break every 20 minutes) CAN NOT DO AT ALL Up to 1/3 of Up to 2/3 of NO the work day the work day RESTRICTION Sitting Standing Walking Climbing Stairs Lifting Bendin.

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