Sample vocational tool

• Author: Scott M. Riemer/Jennifer L. Hess
• Pages: 228-231

Form 6 ERISA Disability Claims and Litigation A-210

FORM 6 SAMPLE VOCATIONAL TOOL

Contact Information

Name:

Phone:

SSN:

Employer/requirements

Your Employer: Your Title:

Salary: $ Bonus: $ Years Employed? Last Day Worked?

Responsibilities/duties of your job:

Average hours per day for each:

1.

2.

3.

4.

5.

How many hours a week do you work? How many hours a week do

you work outside the oce?

Did you have supervisory duties? How many employees did

you supervise?

If your job requires travel, please describe:

PHYSICAL RESPONSIBILITIES Please estimate the number of hours

(or portion of an hour) for each applicable category

Sitting: ___ most hours sitting at one time total hours sitting in a day

Standing: ___ most hours standing at one time total hours standing in a day

Walking: ___ most hours walking at one time total hours walking in a day

Computer use: ___ most hours of computer use at one time total hours of

computer use in a day