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Task | Requirement | Frequency (Place X in approp. box) | |||
Constantly | Frequently | Occasionally | Rarely | ||
Seeing | Yes | X |
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|
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Hearing | Yes | X |
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|
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Tactile Sense |
| X |
|
|
|
Talking | Must convey detailed and important spoken instructions to others accurately | X |
|
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Climbing |
|
|
|
| X |
Balancing |
|
|
| X |
|
Stooping |
|
|
| X |
|
Kneeling |
|
|
| X |
|
Crouching |
|
|
| X |
|
Pulling |
|
| 30 lbs. | 50 lbs. |
|
Pushing |
|
| 30 lbs. | 50 lbs. |
|
Standing |
|
|
| X |
|
Walking |
|
|
| X |
|
Reaching |
|
| X |
|
|
Fine Motor |
| X |
|
|
|
Grasping |
| X |
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|
|
Twisting |
|
| X |
|
|
Repetitive Motions |
| X |
|
|
|
Lifting |
|
| 30 lbs. | 50 lbs. |
|
Crawling |
|
|
|
| X |
Static Position |
|
|
|
| X |
Carrying |
|
|
| 30 lbs. | 50 lbs. |
Other |
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|
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Equipment and Tools
List equipment and tools operated and the frequency of use:
(Those that cannot be delegated to a co-worker.)
Facility Vehicles: Equipment: Communication devices
Tools: Laundry equipment and supplies Other:
Working Conditions
Check which working conditions the employee is subject to:
Physical Conditions:
Extreme temperatures Noise Wet and/or humid Vibration
Workplace Hazards:
X Blood, body fluids and/or infectious disease Hot Water Mechanical Electrical
Chemical Gasses Other___________
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