To establish work restrictions & to increase or decrease the
factors of permanent disability


I, INJURED WORKER, declare as follows:

1. I have read the letter of my Qualified Rehabilitation Representative, [QRR], to Dr. PTP, dated June 17, 2002, and Dr. PTP’s response.

2. There is a misunderstanding in that I am not able to do the tasks set forth in Ms. QRR’s letter for “Handyman position doing light repair for residential property.” Specifically, I am unable to do frequent walking/standing. I can walk a maximum of 20 minutes on flat ground or sidewalks. I cannot do frequent bending below the waist, or kneeling, as I cannot put force on my little toes. I frequently have to shift my weight to my right leg due to lack of strength in my left leg. This then tires my right leg. I used to stand the entire work day. I am not able to climb at all. I used to be able to walk for many hours at a time. Now I avoid walking out of pain in my left foot and leg and fear of falling. I cannot balance well and feel wobbly. I wear a special shoe: which helps a little, but when I walk downhill, the shoe rubs on the scar and hurts. I now cannot lift or carry over 25 pounds. I used to lift up to 80 pounds and carry it around the job site.

3. Further, I do not sleep well, as I am not able to lie comfortably in bed due to a strange pulling sensation in my left foot. Thus I tire easily.

I declare under penalty of perjury, etc.