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 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:Whole body Hand/arm Other (Please describe) Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:: Whole body Hand/arm Other (Please describe) Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:: Whole body Hand/arm Other (Please describe) Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.. _ Part B Local Terms

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) )_ Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:Whole body Hand/arm Other (Please describe) Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:: Whole body Hand/arm Other (Please describe) Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.. PART B TABLE OF CONTENTS

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:: Whole body Hand/arm Other (Please describe) Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.. _

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other ArmOther (please specify) Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:Whole hole body Handand/arm Other (Please describe) Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:: Whole body Hand/arm Other (Please describe) Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.. _ PART B TABLE OF CONTENTS ARTICLE 1 – LEGAL OBLIGATIONS 1

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) )_ Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:: Whole body Hand/arm Other (Please describe) Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:Whole body Hand/arm Other (Please describe) Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.. PART B TABLE OF CONTENTS

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:: Whole body Hand/arm Other (Please describe) Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.. _ Part B Local Terms Part B: Local Terms

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:: Whole body Handand/arm Other (Please describe) Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.. _

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:: Whole body Handand/arm Other (Please describe) Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.

Waist to Shoulder. Full abilities Up to 5 kilograms 5 - 10 kilograms Other (please specify) Stair Climbing: Full abilities Up to 5 steps 5 - 10 steps Other (please specify) _ Bending/twisting repetitive movement of (please specify): Work at or above shoulder activity: _ Limited pushing / pulling with: Left Arm Right Arm Other (please specify) )_ Limited use of hand(s): Left Right Gripping Pinching Other Operating motorized Equipment Environmental Exposure to: (heat, cold, noise) Chemical exposure to: Exposure to Vibration:Whole : hole body Hand/arm Other (Please describe) Prognosis - From the date of this assessment, the above will apply for approximately: 1-2 weeks 3-5 weeks 6-8 weeks 2-3 months 4-6 months 6+ months Unknown Recommendations for work hours and start date: Regular full time hours Modified hours Graduated hours Start Date: (dd/mm/yyyy) Next appointment date to review Limitations and/or Restrictions: (dd/mm/yyyy) Please provide any additional information/comments/findings/limitations (ex. Physical, Cognitive) which you feel would assist our employee in a safe and timely return to work.